Glass. 
Book 



COPYRIGHT DEPOSIT 



Clinical Diagnosis 



A TEXT-BOOK 

of 

CLINICAL MICROSCOPY AND CLINICAL CHEMISTRY 
FOR MEDICAL STUDENTS, LABORATORY 
WORKERS, AND PRACTITIONERS 
OF MEDICINE 



BY 

CHARLES PHILLIPS EMERSON, A.B., M.D. 

LATE RESIDENT PHYSICIAN, THE JOHNS HOPKINS HOSPITAL ; AND ASSOCIATE 
IN MEDICINE, THE JOHNS HOPKINS UNIVERSITY 



SECOND EDITION 




PHILADELPHIA & LONDON 

J. B. LIPPINCOTT COMPANY 



LIBRARY of CONGRESS, 
\ m Cooics Kecei*c« 

SEP ,30 )yob 

wWWJf' Willi* 



Copyright, 1906, by J. B. Lippincott Company 
Copyright, 1908, by J. B. Lippincott Company 



Electrotyped and printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S. A. 



6 b? 0 6 



To 

WILLIAM OSLER, M.D. 

IN GRATEFUL RECOGNITION 
OF THE MANY KINDNESSES 
RECEIVED BY A PUPIL AND 
ASSISTANT, THIS BOOK IS 
AFFECTIONATELY DEDICATED 
BY THE AUTHOR 



PREFACE TO THE SECOND EDITION 



In the preparation of this second edition the author has attempted 
to raise in every possible way the efficiency of this volume as a practical 
work for medical practitioners and students. Fully one-half the work 
has been rewritten, resulting, as will be noticed, in a considerable 
increase in the number of pages. This enlargement permits the incor- 
poration of much new matter throughout, including the bacteriology 
of the sputum and urine, etc., which it is believed will add materially 
to the usefulness of the volume as a working hand-book. Likewise a 
number of new illustrations have been included from microphotographs, 
the work of Drs. Herman Shapiro and T. M. Wright, and original 
drawings by Herman Becker and D. H. Morse. These, by reason of 
their artistic quality and of the subjects they represent, will add much 
to the value of the book. 

The author hereby expresses his deep appreciation of the cordial 
reception given the first edition, and of the kind criticisms and helpful 
suggestions which have indicated lines of improvement and aided in 
the preparation of the present edition. Acknowledgments are due 
Drs. Thomas R. Boggs and Wm. M. Ford, and W. L. Moss for the 
valuable assistance they have rendered. 



PREFACE TO THE FIRST EDITION 



There have, during the past few years, appeared so many and such 
excellent text-books on clinical diagnosis, the clinical examination of 
the blood, the urine, or the gastric contents, that to add to this number 
one which covered the same ground in the same way as they, would 
seem a thankless undertaking, as well as an unpardonable misuse of 
energy. It is because the present work tries to cover this same 
ground in a different way, and one which will, we believe, commend 
itself to the medical profession, that we venture to offer it for inspec- 
tion; we refer to the consideration of clinical laboratory work from 
the clinical rather than from the laboratory point of view. 

This book is based on the author's experience as physician in charge 
of the clinical laboratory, and instructor in medicine, of the Johns 
Hopkins Hospital and University. He has also had at his disposal 
all the clinical records of the ward cases for the seventeen years of this 
hospital's activity. 

Our course in clinical microscopy and chemistry extends over the 
eight months of the student's third year; two afternoons of three 
hours, and one of one hour, each week ; but much of the work is done 
out of class hours, as inspection of pages 447 and 485 will show. The 
subjects studied are the clinical examination of the blood, urine, 
sputum, stomach contents, faeces, and various fluids, as ascitic, pleural, 
cerebrospinal, cyst contents, etc. In addition to this the student 
follows cases assigned him in the out-patient department. To those 
fitted for such work simple problems of research are given. The 
course is a laboratory one ; specimens are provided each of the students. 
It is needless to say that with the eighty microscopes focussed on 
eighty specimens of a patient's blood, sputum, etc., the most of the 
interesting cells or other features will be found. The best were drawn 
by an artist always within call. The questions discussed in the fol- 
lowing pages are for the most part those asked by the students dur- 
ing the class-work. The object of this course is not so much to impart 
knowledge as to raise the efficiency of the student. It is not a course 
in chemistry and microscopy, but in these applied to the study of a 
patient; not in physiology, but in pathology. With the methods of 
chemical and biological work, with the normal findings, they are already 
familiar. Chemistry, inorganic and organic, qualitative and quanti- 

vii 



viii 



PREFACE TO THE FIRST EDITION 



tative, is required for admission to the school ; the normal blood they 
have studied in the anatomical laboratory; normal urine and gastric 
contents, in the laboratory of physiological chemistry. We take this 
knowledge for granted as a foundation for the study of pathological 
bloods, urines, etc., paying particular attention to the clinical signifi- 
cance of these findings. At the same time the students are required to 
practise the best methods in every-day use, not only until they under- 
stand them, but until they can accurately use them. It is the practical 
use of a determination or examination which is emphasized. If approxi- 
mate methods will do, they are used ; if accurate methods are necessary, 
accurate work must be done, whatever the cost in time. To use an 
approximate method well is far better than to employ a more exact, 
laborious one poorly; to do approximate work is not always easy and 
requires practice ; to be able to do accurate work well is also required of 
our students. Practice, experience, an exact knowledge, first of the 
possibilities in a method, second, and just as important, his own 
accuracy in the use of that method — these it is the duty of the clinical 
laboratory to give a student. Above all, he should train his common 
sense so that, using his eyes, nose, ears, and tongue, he can get results 
for which another man would apply elaborate methods. 

The author has been careful not to include new untried methods, 
for of these but a small number will last, and a text-book should 
contain nothing as yet not well tested by friends and foes. It is the 
introduction of " new methods" which renders some books even 
dangerous to the man who buys but one. 

We do not claim that with this book alone the student can study 
clinical microscopy. No subject in medicine is broader or requires 
more reference books, for some of the hardest chemical problems will 
at times confront him, and to interpret the various artefacts and acci- 
dental findings of the microscope would require a vast experience in 
microscopy, and a knowledge of zoology, botany, and mineralogy as 
broad as is the realm of science. For who knows what infusoria, 
what diatom, desmid, or other protophyte, the ovum of what parasite, 
the wing of what insect, the leg of what fly, the tissue of what plant, 
the fibre of what meat, the seeds of what berry or fruit, may be found 
in sputum, stomach contents, urine, or fasces, from the food, tap-water, 
or the contaminations from dirty vessels, or from the dust of the air? 
To be wise in the points of differential chemical and microscopical 
diagnosis is splendid ; but to recognize artefacts and extraneous matter, 
the stumbling-blocks in diagnosis, that is the true test of the clinical 
laboratory worker, and this ability is gained by wide experience alone. 



PREFACE TO THE FIRST EDITION 



ix 



The function of the clinical laboratory worker is to aid the ward 
worker. The findings of the former are seldom conclusive, and must 
be interpreted in the light of the ward findings ; especially is this true 
now that functional diagnosis is the goal. The writer can only give 
to the reader who has aspirations to be a clinical chemist and micro - 
scopist the advice in substance which one of Germany's greatest clinical 
chemists gave him when the latter regretfully left the little Swiss 
laboratory which had been such a pleasant home : the clinical chemist 
must be first a good clinician and second a chemist ; he should remember 
that even from the laboratory point of view his stethoscope is of more 
importance than his microscope, his percussion finger than his whole 
outfit of chemical apparatus. 

In conclusion, we wish to express our indebtedness to Dr. Osier 
for his encouragement and aid during the progress of this work, and for 
his hearty co-operation in placing at our disposal the records of the 
medical wards; and to the assistants and students of this clinic, for 
whose aid I am very grateful, and who are too many to mention by 
name except Dr. Thomas R. Boggs, whose suggestions and criticisms 
have been so valuable. 

I take this opportunity to thank the artists who have done much 
beautiful work for me — Messrs. F. S. Lockwood, Hermann Becker, 
Max Brodel, and Mrs. Ruth Huntington Brodel, whose excellent half- 
tone and pen-and-ink drawings must be recognized by the lack of her 
signature. 

Charles P. Emerson. 

Johns Hopkins Hospital, 1906. 



CONTENTS 



PAGE 

Introduction xxiii 

CHAPTER I. 

THE SPUTUM. 

Introduction 17 

Amount of Sputum 18 

Consistency of Sputum 19 

Reaction of Sputum 19 

Character of Sputum 19 

Color of Sputum 19 

Layer Formation of Sputum 22 

Odor of Sputum 22 

Macroscopic Constituents of Sputum 22 

Microscopic Constituents of Sputum 26 

Plant Parasites in Sputum 35 

Animal Parasites in Sputum 43 

Chemical Examination of Sputum 45 

Sputum in Pulmonary Tuberculosis 46 

Pneumonia 55 

. Influenza 59 

Whooping-cough 63 

Glanders , 63 

Asthma . 63 

Acute Bronchitis 67 

Chronic Bronchitis 69 

Fibrinous Bronchitis 72 

Bronchiectasis 73 

Gangrene of the Lung 75 

Abscess of the Lung 76 

Perforating Empyema 78 

Perforating Serous Pleurisy 78 

(Edema of the Lungs 78 

The Albuminous Sputum of Thoracentesis . 79 

Haemoptysis 80 

Sputum in Hemorrhagic Infarction of the Lung 81 

Chronic Passive Congestion of the Lung 81 

Malignant Disease of the Lung 82 

Mediastinal Growths 82 

Syphilis of the Lung '. 83 

Pneumoconiosis 83 

Sputum in Diphtheria 83 

, Vincent 's Angina 88 

xi 

l f 



Xi'i 



CONTENTS 



CHAPTER n. 

THE URINE. page 

The Collection and Preservation of Urine 90 

The Amount of Urine 91 

The Specific Gravity of Urine 95 

The Color of Urine , . 97 

The Pigments of Urine 98 

The Odor of Urine 103 

The General Appearance of Urine 103 

The Reaction of Urine 103 

The Nitrogenous Bodies of the Urine 109 

Nitrogen 109 

Urea 113 

Uric Acid 117 

Purin Bases 122 

Ammonia 123 

Creatinin 126 

Oxyproteinic and Alloxyproteinic Acids 128 

The Inorganic Acids and Bases of the Urine 129 

Chlorides 129 

Phosphates 133 

Sulphates 138 

Thiosulphuric Acid 143 

Hydrogen Sulphide 143 

Sulphocyanic Acid 143 

Carbonates 143 

Calcium and Magnesium 144 

Sodium and Potassium 145 

Iron 145 

Lead 146 

Arsenic 146 

The Pigments of the Urine 146 

Indoxyl Sulphate 146 

Skatoxyl Sulphate 149 

Indigo-Red 150 

Paracresol and Phenolsulphuric Acid 151 

Potassium Iodide 151 

Bile Pigments 151 

Bilirubin 152 

Biliverdin 153 

Hy drobili rubin 1 53 

Bilifuscin. 153 

Biliprasin 153 

Cholecyanin 1 53 

Choletelin 154 

The Reducible Body of Stokvis 154 

Tests for Bile Pigments 154 

Melanin and Melanogen 157 

Rosenbach's Reaction 158 

Bile Acids 158 

DiazoTest 159 

Ferments in the Urine 164 



CONTENTS xiii 

PAGE 

Carbohydrates and Allied Bodies in the Urine 165 

Glucose: 166 

Levulose 184 

Lactose 185 

Pentose 186 

Inosite 189 

Glycogen or Erythrodextrin 189 

Animal Gum 190 

Laiose 190 

Maltose 190 

Isomaltose 190 

Melituria 190 

Acetone 190 

Diacetic Acid 195 

Oxybutyric Acid 197 

Diabetes Mellitus 199 

Diabetes Insipidus 204 

Glycuronic Acid 205 

Alkaptonuria 206 

Homogentisinic Acid 207 

Uroleucinic Acid 207 

Proteids in the Urine 208 

Albumin Tests 208 

Proteids present 217 

Serum Albumin 217 

Serum Globulin 218 

Euglobulin, Nucleo- Albumin, Mucin, Morner's Body 219 

Nucleohiston 223 

Fibrinogen, fibrinoglobulin 224 

Albuminuria without Definite Renal Lesion 224 

Physiological Albuminuria 224 

Functional Albuminuria 225 

Albuminuria of the New-born 228 

Albuminuria of Women in Labor 228 

Albuminuria of Adolescence 229 

Cyclic Albuminuria 230 

Hypostatic Albuminuria 232 

Albuminuria Minima 232 

Intermittent Albuminuria 232 

Traumatic Albuminuria 233 

Febrile Albuminuria 233 

Haematogenous Albuminuria 233 

Nervous Form of Albuminuria 234 

Albuminuria with Definite Renal Lesion 234 

Organic Bright 's Disease 234 

Hetero- Albumosuria, Bence- Jones Body 235 

Albumosuria, Deutero- Albumosuria, Peptonuria 237 

Hsematuria 240 

Haemoglobinuria 241 

Methaemoglobinuria 245 

Hsematoporphyrinuria 246 

Sediments 246 

Preservation 246 



xiv CONTENTS 

PA.GE 

Unorganized Sediments 248 

Urates and Uric Acid 248 

Phosphates and Carbonates 251 

Oxalates 253 

Sulphates 256 

Hippuric Acid 256 

Hetero-Albumose 256 

Xanthin 256 

Haematoidin (Bilirubin) 256 

Indigo 257 

Melanin 257 

Haemoglobin 257 

Cholesterin 257 

Leucin 257 

Tyrosin 257 

Cystin 260 

The Diamines 261 

Scheme of Sediments 261 

Chyluria 263 

Lipuria 264 

Organized Sediments 265 

Mucous Sediment 265 

Epithelial Cells , 265 

Casts 268 

Epithelial 268 

Granular 268 

Fatty 269 

Waxy 269 

Hyaline, Colloid, Glassy 270 

Blood 270 

Haemoglobin 270 

Pus 270 

Cylindroids 271 

Combined Casts 272 

Pseudo-Casts 272 

Cylindruria 275 

Testicular Casts 277 

Tissue Fragments 278 

Pus-Cells 278 

Red Corpuscles 279 

Concretions 280 

Urate 280 

Oxalate 280 

Phosphate 281 

Carbonate 281 

Cystin 281 

Xanthin. * 281 

Fatty 282 

Indigo 282 

Albumin 282 

Table of 282 

Bacteriology of the Urine 283 

Technic of Obtaining Specimens 283 



CONTENTS xv 

PAGE 

Bacteriology of the Urine: Bacterioscopic Examination 283 

Bacterial Stains . 284 

Flagella Staining 285 

Cultural Method 287 

Organisms that may be found in the Urine 288 

Bacillus Coli Communis 289 

Bacillus Typhosus 289 

The Paratyphoid Group 289 

Bacillus Lactis Aerogenes 289 

Bacillus Alkaligenes 290 

The Proteus Group 290 

Bacillus Pyocyaneus 290 

Bacillus Aerogenes Capsulatus 290 

Bacillus Tetani 291 

Staphylococcus Pyogenes Aureus 291 

Staphylococcus Pyogenes Albus 291 

Staphylococcus Epidermidis Albus 292 

Streptococcus Pyogenes 292 

Septicaemia 293 

Infectious Nephritis 293 

Acute Pyelitis 294 

Cystitis 294 

Bacteriuria 297 

Infection of Urethra and External Genitals 297 

Acute Anterior Urethritis 299 

Posterior Urethritis 299 

Non-specific Urethritis 300 

Bacteriorrhcea 300 

Prostatitis 301 

Bacteriology of External Genitalia 302 

Bacillus Ulceris Cancrosi 302 

Trepanoma Pallida 302 

Spirochaeta Refringens 304 

Yeasts, Moulds, Sarcinae 304 

Animal Parasites 304 

Prostatic Fluid 306 

Tripperfaden 308 

Diseases of the Kidneys 309 

Fevers, Congestion, etc 310 

Acute Nephritis 311 

Subacute Nephritis 313 

Chronic Nephritis 313 

. Uraemia 317 

Renal Atrophy 318 

Congenital Cystic Kidney '. 319 

Suppurative Nephritis 319 

Cancer of the Kidney 319 

Abscess of the Kidney 319 

Tuberculosis of the Kidney 319 

Infarction of the Kidney 320 

Pyelitis, Pyelonephritis 320 

Hydronephrosis, Pyonephrosis, Uronephrosis 321 

Renal Calculus 321 



xiv CONTENTS 

PA.GB 

Unorganized Sediments 248 

Urates and Uric Acid 248 

Phosphates and Carbonates 251 

Oxalates 253 

Sulphates 256 

Hippuric Acid 256 

Hetero-Albumose 256 

Xantlun 256 

Haematoidin (Bilirubin) 256 

Indigo 257 

Melanin 257 

Haemoglobin 257 

Cholesterin 257 

Leucin 257 

Tyrosin 257 

Cystin 260 

The Diamines 261 

Scheme of Sediments 261 

Chyluria 263 

Lipuria 264 

Organized Sediments 265 

Mucous Sediment 265 

Epithelial Cells , 265 

Casts 268 

Epithelial 268 

Granular 268 

Fatty 269 

Waxy .....269 

Hyaline, Colloid, Glassy 270 

Blood 270 

Haemoglobin 270 

Pus 270 

Cylindroids 271 

Combined Casts 272 

Pseudo-Casts 272 

Cylindruria 275 

Testicular Casts 277 

Tissue Fragments 278 

Pus-Cells 278 

Red Corpuscles 279 

Concretions 280 

Urate 280 

Oxalate f? 280 

Phosphate 281 

Carbonate 

Cystin 281 

Xanthin 281 

Fatty 282 

Indigo 282 

Albumin 282 

Table of 282 

Bacteriology of the Urine 283 

Technic of Obtaining Specimens 283 



CONTEXTS xv 

PAGE 

Bacteriology of the Urine: Bacterioscopic Examination 283 

Bacterial Stains . 284 

Flagella Staining 285 

Cultural Method 287 

Organisms that may be found in the Urine 288 

Bacillus Coli Communis 289 

Bacillus Typhosus 289 

The Paratyphoid Group 289 

Bacillus Lactis Aerogenes 289 

Bacillus Alkaligenes 290 

The Proteus Group 290 

Bacillus Pyocyaneus 290 

Bacillus Aerogenes Capsulatus 290 

Bacillus Tetani 291 

Staphylococcus Pyogenes Aureus 291 

Staphylococcus Pyogenes Albus 291 

Staphylococcus Epidermidis Albus 292 

Streptococcus Pyogenes 292 

Septicaemia 293 

Infectious Nephritis 293 

Acute Pyelitis 294 

Cystitis 294 

Bacteriuria 297 

Infection of Urethra and External Genitals 297 

Acute Anterior Urethritis 299 

Posterior Urethritis 299 

Non-specific Urethritis 300 

Bacteriorrhcea 300 

Prostatitis 301 

Bacteriology of External Genitalia 302 

Bacillus Ulceris Cancrosi 302 

Trepanoma Pallida 302 

Spirochseta Refringens 304 

Yeasts, Moulds, Sarcinse 304 

Animal Parasites 304 

Prostatic Fluid 306 

Tripperfaden 308 

Diseases of the Kidneys 309 

Fevers, Congestion, etc 310 

Acute Nephritis 311 

Subacute Nephritis 313 

Chronic Nephritis 313 

Uraemia 317 

Renal Atrophy 318 

Congenital Cystic Kidney 319 

Suppurative Nephritis 319 

Cancer of the Kidney 319 

Abscess of the Kidney 319 

Tuberculosis of the Kidney 319 

Infarction of the Kidney 320 

Pyelitis, Pyelonephritis 320 

Hydronephrosis, Pyonephrosis, Uronephrosis 321 

Renal Calculus 321 



xvi • CONTENTS 

PAGE 

Diseases of the Kidneys: Parasitic Diseases 321 

Functional Renal Diagnosis 322 

Cryoscopy 323 

Electrical Conductivity 329 

Delayed Urea Excretion 330 

Chloride Excretion 331 

Dilution Test 331 

Renal Permeability 332 

Methylene-Blue Test 332 

Salicylic Acid Test 333 

Phlorizin Test 334 

Value of Tests 334 

CHAPTER III. 

THE STOMACH CONTENTS. 

TheVomitus 338 

The Fasting Stomach 341 

Test Meals 341 

Gastric Acidity 343 

Total Acidity 345 

Free Acid 346 

Acid Deficit 347 

Total Hydrochloric Acid 348 

Value of Tests for Acidity 349 

Physiology of Gastric Secretion 350 

Diagnostic Value. . , 350 

Pepsin 352 

Fat-Splitting Ferment 355 

Rennet 356 

Extent of Gastric Digestion 356 

Products of Albumin Digestion 357 

Starch Digestion 357 

Lactic Acid 357 

Other Organic Acids 360 

Bases of Gastric Juice 360 

Fermentation 361 

Microscopic Examination 362 

Absorption Power of Stomach 364 

Motility of Stomach 365 

Hyperacidity 367 

Hypersecretion 368 

Nervous Dyspepsia 340 

Acute Gastritis 371 

Chronic Gastritis 371 

Atrophy of Mucosa 373 

Ulcer of Stomach 374 

Cancer of Stomach 376 

CHAPTER IV. 

THE INTESTINAL CONTENTS AND FAECES. 

Motility of Intestine 384 

Pancreatic Fluid 384 



CONTENTS xvii 

PAGE 

Pancreatic Fluid: Trypsin ] 384 

Fat-Splitting Ferment 384 

Diastase 385 

Test Meals 385 

Digestive Power of Pancreatic Juice 385 

Examination of Stools 386 

The Constituents of Normal Stools 386 

The Reaction of the Stools 387 

The Frequency of the Stools 387 

The Consistency and Form of the Stools 387 

The Color of the Stools 388 

Acholic Stools 388 

Fatty Stools 390 

Mucus in the Stools 393 

Blood in the Stools 394 

Pus in the Stools 396 

Undigested Food in the Stools 397 

Microscopy of the Stools 398 

Macroscopic Examination of the Stools 399 

Concretions 399 

Intestinal Parasites 402 

Plant Parasites 419 

Stools in Disease 421 

Typhoid Fever 421 

Asiatic Cholera 422 

Dysentery, Rectal Diarrhoea, Cancer of the Rectum 424 

Amoebic Dysentery 424 

Pancreatic Disease 424 

Permanent Mounts of Small Worms 425 

To Preserve Stools Containing Parasite Eggs 425 

Stained Specimens of Worms 425 

CHAPTER V. 

THE BLOOD. 

Technic 426 

Fresh Blood 429 

Red Cells 429 

Degenerations 433 

Leucocytes 435 

Haemokonien Granules 437 

Fat 448 

Platelets.. 448 

Fibrin Network 448 

Counting Red Cells 448 

Counting Leucocytes 450 

Blood Staining 452 

Specific Gravity of the Blood 460 

Dried Residue 463 

Sedimentation of the Blood 463 

Coagulation of the Blood 464 

Fibrin Diagnosis 467 

Bacteriology of the Blood 468 



xviii CONTENTS 

PAGE 

Serum Diagnosis 470 

Red Cells : ." 475 

Shape. 476 

Structure 476 

Size 477 

Staining Properties 478 

Granules of Red Cells 480 

Number of Red Cells 483 

Physiological Variations 484 

Drugs and Therapeutic Measures 487 

Pathological Variations 487 

Resistance of Red Cells 489 

Haemoglobin 490 

Leucocytes 502 

Granules 502 

Classification of Cells 505 

Bone Marrow 511 

Nucleated Reds 512 

Origin of Red Cells 516 

Origin of Leucocytes 518 

Fcetal Blood 521 

Leucocytosis 521 

Physiological -. 523 

Inflammatory 525 

Pseudoleucocytosis 530 

Malignant Disease. 530 

Post-hemorrhagic 53 0 

Agonal 531 

Medicinal 531 

Mixed Cell Leucocytosis 532 

Mastzell Leucocytosis 532 

Lymphocytosis 532 

Leucopenia 533 

Eosinophilia • 534 

Iodophilia 537 

Blood Platelets 538 

Reaction of the Blood 542 

Urea in the Blood 547 

Anaemia. 547 

Secondary 549 

Simple Primary 561 

Progressive Pernicious 561 

Chlorosis 573 

Leukaemia 576 

Myelogenous 577 

Lymphatic (Lymphaemia) 583 

Acute 586 

Anaemia: Leukaemia: Mixed 588 

Pseudoleukaemia 589 

Hodgkin's Disease 589 

Tuberculous Adenitis 590 

Leukanaemia 590 

Blood in Acute Diseases 590 



CONTENTS xix 

PAGE 

Blood in Chronic Diseases 608 

Value of Blood Examination 622 

Malaria 624 

Fresh Blood 624 

Tertian 624 

Quartan , 627 

^Estivo- Autumnal 629 

Cycle in the Mosquito 631 

In Stained Specimens 634 

Trypanosomiasis 638 

Pyroplasmosis 640 

Filariasis 641 

Relapsing Fever 643 

Opsonins : 643 

The Opsonic Index 648 

Value of the Opsonic Index 648 

Fixation of Complement 651 

CHAPTER VI. 

VARIOUS BODY FLUIDS. 

Determination of Specific Gravity 657 

Determination of Various Proteids 657 

Determination of Fat, etc 658 

Cerebrospinal Fluid 661 

Transudates and Exudates 666 

Peritoneal Fluid . 666 

Pleural Fluid .' 667 

Synovial Fluid 669 

Chylous Fluids 669 

Ovarian Cysts 671 

Hydrocele 674 

Spermatocele • 674 

Tophi of Gout 674 

Urea on the Skin 674 



LIST OF ILLUSTRATIONS 



Plate I. Blood-cells, Ehrlich's stain 476 

" II. Leucocytes, platelets, and Trypanosoma, Hastings' stain 506 

III. Malaria (stained) 624 

" IV. Parasites of tertian fever and quartan fever 628 

" V. Parasite of aestivo-autumnal fever 630 



FIG. PAGE 



1. Spiral thread of mucus from sputum 23 

2. Extraneous matter common in the 

sputum 26 

3. Epithelial cells found in sputum 28 

4. Elastic tissue from tuberculous sputum 30 

5. Elastic tissue from tuberculous sputum 

showing alveolar arrangement 30 

6. Fatty acid crystals in sputum 32 

7. Leptothrix form in sputum 32 

8. Elastic tissue in sputum from food 33 

9. Mucor mucedo 38 

10. Aspergillus fumigatus 39 

11. Aspergillus flavus 40 

12. Penicillium glaucum 41 

13. Egg of Paragonimus westermanii 44 

14. Bacillus tuberculosis 51 

15. Fibrin cast of the primary bronchi . . 58 

16. Bacillus influenzae 62 

17. Curschmann's spiral 64 

18. Free central fibre from a Curschmann 

spiral 65 

19. Bacillus diphtherial 84 

20. Smear from case of Vincent's angina. . 88 

21. Kjeldahl apparatus for nitrogen de- 

termination 112 

22. Schlosing's apparatus for ammonia 

determination 125 

23. Folin's apparatus for ammonia and 

acetone determination 126 

24. Apparatus for determining the melting 

point of crystals 175 

25. Half-shadow saccharometer 181 

26 and 27. Fields of a saccharometer 182 

28. Iodoform crystals 192 

29. The horismascope 211 

30. Esbach's albuminometer 215 

31. Hsemin crystals 244 

32. Ammonium biurate crystals 249 

33. Bile-stained calcium phosphate sheaves 250 

34. Uric acid crystals 250 

35. Triple phosphate crystals 251 

36. Atypical triple phosphate crystals 252 

37. Dicalcium phosphate crystals 252 

38. Calcium phosphate crystals 253 

39. Calcium carbonate dumb-bells 254 

40. Calcium oxalate crystals and spheres. . 254 

41. Calcium oxalate plates 254 

42. Various crystals 256 



FIG. PAGE 

43. Haematoidin, leucin, tyrosin, xanthin. . . 257 

44. Cystin crystals 260 

45. Epithelial cells from urethra 265 

46. Epithelial cells from urine 266 

47. Epithelial cast and cells, pseudopus 

cast, etc 267 

48. Coarsely and finely granular casts 268 

49. Waxy casts 268 

50. Epithelial, fatty, and pus casts 269 

51. Hyaline casts '. . . . 271 

52. Blood-cast 271 

53. Cylindroids 272 

54. Pseudo-casts 273 

54a Micrococcus aureus 292 

54b Streptococcus pyogenes 292 

54c The gonococcus 298 

55. Elements from Echinococcus cyst 305 

56. Fragment from Echinococcus cyst wall . 305 

57. Schistosomum haematobium 306 

58. Accidental urinary sediments, proto- 

phytes, etc 306 

58a Eggs of Eustrongylus gigas 306 

59. Prostate fluid 307 

60. Prostate fluid 308 

60a Cells in prostatic fluid 308 

61. Mucus mass full of spermatozoa 309 

62. Apparatus for cryoscopy 325 

63. Strauss funnel for lactic acid test 358 

64. Sarcina ventriculi and yeast cells 380 

65. Fats and soaps in stools 391 

66. Fatty acid crystals 392 

67. Charcot-Leyden crystals 399 

68. Pseudo-eggs in stools 400 

69. Cells in stools 400 

70. Spines forming the "down" of fruits. . 400 

71. Amceba coli 402 

72 Amceba coli 402 

72a Trichina spiralis . 402 

73. Eggs of Trichocephalus dispar and of 

Ascaris lumbricoides 404 

73a Eggs of Tyroglyphus siro 404 

74. Trichomonas vaginalis 405 

75. Lamblia intestinalis 406 

76. Balantidium coli 407 

77. Oxyuris vermicularis 409 

78. Ankylostoma dr.odenale 410 

79. Caudal bursa of Uncinaria americana. . 411 

80. Caudal bursa of Uncinaria duodenalis. 412 



XXI 



LIST OF ILLUSTRATIONS. 



xxii 



FIG. PAGE 

81. Head of Uncinaria americana 412 

82. Head of Uncinaria duodenalis 412 

83. Egg of Uncinaria duodenalis 413 

84. Larva of Uncinaria americana 413 

85. Distoma lanceolatum 414 

86. Taenia solium — head, link, and egg 415 

87. Head of Taenia sagmata 416 

88. Links of Taenia saginata 416 

89. Eggs of Taenia saginata 416 

S9a Links of Taenia solium 416 

90. Hymenolepis nana 417 

91. Bothrioceplialus latus 418 

92a Egg of Schistosoma haematobium .... 419 
92b Egg of Schistosoma haematobium . . 419 
92c Bacillus bifidus 420 

93. Fresh blood-cells 434 

94. Thoma-Zeiss haemocytometer 438 

95. Field of ruled slide 441 

96. Scheme of ruled slide 442 

97. Arm of haematocrit 450 

98. Method of making smears 453 

99. Boggs's modification of Russell-Brodie 

coagulometer 466 

100. Diagrams of the movement of cells in 

the coagulometer 466 

101. Tubes for collection of blood for 

serum-diagnosis 471 

102. Tube for diluting serum 472 

103. Widal test, negative result 473 

104. Widal test, positive result 474 

105. Meischer's modification of the Fleischl 

haemoglobinometer 491 

106. Mixing pipette for the Miescher haemo- 

globinometer 492 

107. Color prism for the Miescher haemo- 

globinometer 493 



FIG. PAGE 



108. Pipette for the Fleischl haemoglobino- 

meter 493 

109. Gowers's haemoglobinometer 495 

110. Sahli's haemometer 495 

111. Dare's haemoglobinometer 497 

112. Pipette of Dare's haemoglobino- 

meter 497 

113. Nucleated red cells of fetal blood 512 

114. Blood platelets 539 

115. Haemamceba leukaemiae magna et 

parva; large granular cell of bone 

marrow 588 

116. The development of the malaria 

parasite in the mosquito's stomach 632 

117. Intestine of an infected mosquito with 

oocysts 632 

118. Culex and Anopheles mosquitoes 633 

119. -Heads of mosquitoes 634 

120. Leishman-Donovan bodies 640 

121. Filaria bancrofti 641 

122. Spirochaete obermeyeri 643 

122a Method of obtaining blood 646 

122b Tubes used in serum work 646 

122c Smear of spinal fluid of a case of 

epidemic cerebrospinal meningitis. . 665 
122d Smear of spinal fluid of a case of 
meningitis due to Diplococcus lanceo- 

latus 665 

122e Smear of spinal fluid of a case of 
meningitis due to Bacillus influ- 
enzae 666 

123. CeUs from a pleural fluid 668 

124. Fatty acid crystals from an ovarian 

cyst 671 

125. Cholesterin crystals 672 

126. Sodium biurate crystals 673 



INTRODUCTION 



The clinical laboratory has two special functions in the medical 
school, — in it the student learns the application of physical and chemi- 
cal methods in the study of disease, and in it researches are conducted 
on the innumerable problems concerning etiology, diagnosis, and treat- 
ment. Forming an essential part of the hospital-half of a school, it 
should be close to the wards and so arranged as to have ample facilities 
for the students and for the house physicians and others doing special 
work. It should be in charge of a man resident in the hospital, 
familiar with the routine of the clinic, and in close daily touch with 
his chief and with the assistants. The expenses should be shared 
equally by the hospital and the medical school. Into the details of 
organization I will not enter, but the director of such a laboratory 
should, if possible, have assistants thoroughly trained in bacteriology, 
physiological methods, and physiological chemistry. 

In 1896, through the kindness of two ladies, a special clinical 
laboratory was built for the students of the Johns Hopkins Medical 
School, which was enlarged two years ago when the new clinical 
building was erected. On each of the two floors about fifty students 
are accommodated and there are rooms adjacent for special workers 
and for the assistants. Dr. Jesse Lazear was at first in charge, and 
under Dr. Thayer's direction the well-known researches of Macallum 
and Opie and of Lazear himself on malaria were carried on. In 1900, 
after Dr. Lazear went to Cuba, we were fortunate enough to have Dr. 
Charles P. Emerson take charge of the laboratory, and to him the 
medical school is deeply indebted for the organization of clinical 
laboratory courses of the most thorough and scientific character. 

In medical education the all-important problem is to give a man 
the knowledge he can use. In our modern system much of the train- 
ing is rendered ineffective, as it has not been sufficiently prolonged 
to become part of a man's intellectual or bodily mechanism. A brief 
course of six weeks on any practical subject is almost useless and in 
some may be positively dangerous. When possible, an orderly 
sequence should be followed, so that the work of each year 
shall supplement that of the preceding. In the seven-year course 
laid down by the Johns Hopkins University a thorough laboratory 
training in biology, physics, and chemistry is given before the profes- 

xxiii 



XXIV 



INTRODUCTION 



sional work begins, so that a man enters the medical school proper 
with a practical knowledge of scientific methods and of the use of 
instruments of precision. In his first year of the medical curriculum 
the courses in histology and physiology and in the second year those 
in physiology, bacteriology, physiological chemistry, and pathological 
histology give him an insight into the structure and functions of the 
body, and he becomes thoroughly familiar with the use of all instru- 
ments of precision. In the third and fourth years in the hospital side 
of his education, for which the previous ones have been a preparation, 
he must have opportunities to carry on his practical work, and these 
the clinical laboratory affords. A student who has been interested 
in the mysteries and mechanism of cardiac rhythm in the physiological 
course should be able to take the pulse and heart tracings of the first 
case of mitral disease that he meets in the out-patient department, and 
the means should be afforded him to pass without a jar from the 
normal to the abnormal, — without, indeed, appreciating that there is 
any difference in the method of approaching the problems involved. 
So too a student should be able at once to attack his first case of 
diabetes as a problem in carbohydrate metabolism, fully prepared by 
previous study to approach it on the clinical side. 

If the curriculum were not so full, a student could gradually work 
out for himself, as the patients came under observation, every detail 
in the application of scientific methods to clinical study, but it is found 
more convenient to group them together and present in orderly 
sequence the subjects for study. Concurrently with the systematic 
instruction in the out-patient department which forms a large part 
of the work of the third year, a course on microscopical and chemical 
methods is given, and each man has his own place in the laboratory 
at which he may work throughout the year. This book is the outcome 
of the work by Dr. Emerson and his students in this course during 
the past five years. Not only does it represent the results of a very 
large number of careful observations made in the laboratory, but 
an analysis of many important groups of cases in the wards, so that 
it illustrates the experience of the medical clinic of this hospital so far 
as it relates to microscopical and chemical methods of diagnosis. 
The work will be found a comprehensive and trustworthy guide in 
all the details of laboratory work. 

But the aim of a training such as this book implies is to send 
out into practice men able to give patients the benefit of modern scien- 
tific methods in the diagnosis and treatment of disease — men who use 



INTRODUCTION 



XXV 



the microscope, who examine sputum, and who use the stethoscope, 
and who can do the routine urine and blood work with confidence. 
The men to study a book of this kind are the young practitioners who 
are keeping up the practical knowledge obtained in the medical school, 
and who appreciate a small laboratory as the most valuable stock-in- 
trade. As a practitioner becomes more and more engaged, he can 
hand over to an assistant the laboratory side of the work, but it is 
surprising how much can be done even by the busiest of men if the 
will is there and if the methods have once been thoroughly mastered. 

William Osler. 

January 30, 1906. 



CLINICAL DIAGNOSIS 



CHAPTER I 
THE SPUTUM 

Introduction. — The examination of the sputum is fast becoming 
a lost art. The discovery of a few specific organisms and the hope of 
finding more have had as their result the neglect of the study of fresh 
sputum ; the many points which observers of only one generation back 
carefully noted are now either not looked for, or if they are, are often 
not seen; a rich nomenclature is forgotten, especially the Latin por- 
tion, with the exception of a few terms borrowed from the kitchen. 
Yet, on the whole, in following a case the careful study of the sputum 
in the fresh state is very important, and the student who is encouraged, 
even required, to do this thoroughly, will soon learn that our fathers 
who never saw a germ could still diagnose and follow cases with an 
acuity with which he usually does not credit them. 

In the examination of fresh sputum the eyes and nose must be 
trained so that the physician may be able by simple observation to form 
a judgment concerning the nature of the case, its stage, or the com- 
plication which it then presents. For these colors, characteristics, and 
structures do exist and are to be seen; some are important, and if 
others are not it is well to know that much ; that bacteria in chains 
are not elastic tissue ; a spiral vegetable cell, not a parasite. To search 
for a parasite is well, but to draw expensive pictures of a few starch 
granules, confidently expecting that a new one has been discovered, 
means that the fresh sputum was not systematically studied during 
student days. 

The sputum is, strictly speaking, that substance or mass of sub- 
stances which is expectorated; in a more common and more limited 
sense it is that which comes from the respiratory passages, from 
alveoli to larynx. In its wider sense, considering the variety of 
sources which may contribute, its importance is great; for besides 
those from all parts of the respiratory passages it may contain con- 
stituents from the oesophagus, nose, mouth, or, through perforation 
into these, from any neighboring organ. 

The presence of any sputum at all is usually considered pathologi- 
cal, and, as a rule, normal persons can raise by coughing either nothing 
or very little. 

2 17 



IS 



CLERICAL DIAGNOSIS 



But the respiratory passages are lined with mucous membrane 
which may secrete mucus in such amounts that it must be expectorated. 
Persons living in an atmosphere laden with dust expectorate every 
morning the excess of mucus secreted and the dust inhaled during the 
preceding day, all of which has been swept during the night by the 
indefatigable cilia to the larynx. 

This morning sputum, which is small in amount, is expectorated 
in lumps often as large as a cherry, is tough, elastic, gray in color 
from the coal-dust, and with often a translucency like boiled sago 
due to myelin. Microscopically, it is of streaked mucus, " the more 
viscid streaks arising from the goblet cells, the watery from glands " 
(Panizza), and arranged in lines are epithelial and pus-cells loaded 
with coal pigment and myelin. In addition are non-nucleated cell- 
like masses, probably degenerated epithelium, and pus-cells clumped 
together in balls, which as a rule contain no pigment. 

When sputum is present in pathological amounts it is raised by 
coughing, unless in such amounts and with sufficient vis a tergo as to 
flow from the mouth. But there are a certain number of patients who, 
although there is sufficient sputum for examination, persist in swallow- 
ing it, and these must be taught to expectorate. This is particularly 
true of children, of persons of filthy habits, and, of course, of partially 
unconscious patients. The doctor is rewarded for the time spent in 
urging those patients who can to expectorate. 

One of Dr. Osier's assistants created some amusement by assiduously sitting 
by the bedside of a case with suspicious lung signs begging her to expectorate. At 
last he got a very little sputum, but it contained tubercle bacilli, and the hospital 
record for early diagnosis of the pneumonic type of pulmonary tuberculosis was 
broken. 

In some cases the swallowed sputum is obtained by washing out 
the stomach. In children the stools must be examined. In the case 
of young children the point mentioned by Findlay is valuable ; the 
finger, covered with gauze, is put into the child's throat to stimulate 
coughing, and the sputum wiped out with this finger. 

The patient must be carefully taught to avoid expectorating 
saliva, nasal and pharyngeal mucus, etc., into the cup. 

Amount. — Some general idea of the quantity expectorated is 
always necessary. The accurate measurement of the twenty-four hour 
amount, though rarely valuable, is often an aid in following a case. 

In some cases, although rare, with severe cough, the sputum is so 
small in amount and so viscid that there is practically none obtained. 
Such are cases of " dry " bronchitis, diffuse bronchitis, incipient tu- 
berculosis, rare cases of lobar pneumonia, and of caseous pneumonia. 
Very much is present in certain cases of chronic bronchitis, in advanced 



THE SPUTUM 



19 



tuberculosis with large cavities, bronchiectasis, gangrene of the lung, 
oedema ; in hemorrhage, perforating pleural exudate, and lung abscess 
the blood or pus may pour from the mouth, or even drown the patient. 
After too rapidly or thoroughly tapping the chest the amount of albu- 
minous sputum may be great. 

The clinical chemist engaged in metabolism experiments must re- 
member to take an abundant sputum into account, since the amount of 
nitrogen thus eliminated may be even 5 per cent, of the total output. 

Consistency. — Generally speaking, this varies inversely as the 
amount, except in pneumonia, in which case, although abundant, it 
will not drop from the inverted cup. In true bronchial asthma dur- 
ing the first of the attack, acute bronchitis, and pertussis it may be 
very tenacious. As a rule, this characteristic is due to mucin. The 
explanation in the case of pneumonic sputum with little mucin is not 
so easy, since the water-content is so high. It is ascribed to the nu- 
cleins present in abundance, and these in alkaline medium. On the con- 
trary, when there is little mucus and much water, as in oedema of the 
lungs, or pus poured from a bronchial tree denuded of its mucous 
membrane, it is very watery. 

Reaction. — When fresh, the sputum is alkaline in reaction. That 
which has stood some time in the cup, or sputum which has stagnated 
in the body, is acid. 

Character — Mucoid sputum is glairy, transparent, and tenacious. 
If acetic acid be added, it becomes cloudy (due to the mucin). Such 
sputum is seen in acute bronchitis, pertussis, and early in asthma. 

A mucopurulent sputum is one in which there are enough pus- 
cells to change the color macroscopically. There is every gradation 
from one almost mucoid to pure pus. Small amounts of pus give a 
whitish color, more, a yellow or yellowish-green, the exact reason of 
which is uncertain. There are two varieties of mucopurulent sputum ; 
in the one the body of the sputum is pure mucus, and in it are sus- 
pended streaks and dots of pus. In the other obtains a homogeneous 
mixture of mucus and pus, yet not enough of the latter to merit the 
use of the term purulent. Such sputum is only slightly opaque. 

Purulent sputum is said to differ from pure pus only in the 
tenacity due to mucus ; but this distinction is artificial, since in bron- 
cho-blennorrhoea there is little normal mucous membrane left. Pure 
pus may constitute the sputum in ruptured empyema, abscess of lung, 
rupture of an abscess of a neighboring organ through the lung, trachea, 
oesophagus, or nasal passages. 

Serous sputum is colorless, and very frothy from the high per- 
centage of albumin. It is seen in oedema of the lung, perforating 
serous pleurisy, and in rare cases following thoracentesis. 

Color. — Bloody sputum may be almost pure blood, or gain the 



20 



CLINICAL DIAGNOSIS 



name from its slight blood-staining. It is found after trauma, hemor- 
rhagic infarction of the lung, gangrene, early in acute lobar and also 
caseous pneumonia, pulmonary tuberculosis, tumors of the lung, in- 
tense chronic passive congestion, and " weeping" aneurism. As a rule, 
the blood is mixed with mucus, hence is covered by a frothy layer. 
The blood may be due to diapedesis or to the rupture of a vessel. 
Hemorrhagic sputum is in the former case a sign of severe inflamma- 
tion of the lung, but of no one disease (see page 80). 

Sputa colored by the derivatives of hemoglobin may be of almost 
any color. Formerly it was taught that varying amounts of blood 
could explain this variety of colors, but Traube proved that unchanged 
blood-cells could give only a red color or reddish tint. Blood-cells 
retained in the lung, either in alveoli, bronchi, or tissue, soon lose their 
haemoglobin, and the various oxidation products of this can give that 
wide range of color seen, for instance, in a subcutaneous bruise; 
various shades of red, brown, green, orange, yellow, chocolate. A few 
cells may be found, but they are pale and swollen. The best example 
is the typical rusty sputum of pneumonia, the color of which is due to 
an unknown derivative of haemoglobin, but the sputum may be any 
shade of green or yellow, red, or brown. After hemorrhage into the 
lung-tissue, cavities, or alveoli, and the diapedesis occurring in chronic 
passive congestion due, for instance, to mitral disease, there may be 
sufficient epithelial cells loaded with granules of changed blood pig- 
ment to give a characteristic light brown color to the sputum. In 
destructive processes there is sometimes sufficient haematoidin present 
to give the sputum a dirty brown color. Such is the case in gangrene, 
abscess, infarction, and chronic passive congestion. These crystals 
may literally fill the sputum. 

Bile pigments are present in the sputum in case a liver abscess per- 
forates through the lung or the person is jaundiced, but except in 
icterus the term " jaundiced" should not be used. It is granted that 
chemically the difference between the pigments of bile-stained and 
similarly appearing sputum with oxidized haemoglobin is nil, and this 
may be true of haematoidin, but, clinically, the difference between these 
sputa is too important to neglect. 

As green sputa are of such importance they should be grouped 
together. When a patient is jaundiced, the pure mucoid sputum of a 
bronchitis, for example, may be of a fine grass-green color. In such 
cases it is the oxidized bile pigment which gives the tint. But when 
no jaundice is present, exactly the same color (due to the same pig- 
ment, perhaps, but with a very different significance) is sometimes 
seen. This occurs in ordinary croupous pneumonia during lysis; in 
which case the pigment is oxidized before expectorated, a process for 
which there is hardly time in an ordinarily sharp attack; pneumonia 



THE SPUTUM 



21 



ending in abscess ; and subacute caseous pneumonia. It is interesting 
that Traube, 1 who first called attention to these green sputa, gives 
illustrations of caseous pneumonia alone. In the five cases he cited it 
was an early feature in three, lasting two to five days, in two for two 
weeks ; it did not remain green in any case till death ; in one case the 
onset of a fresh involvement was accompanied by a return to rusty 
sputum. In some cases of certain green tumors (chloroma) of the 
lung there is green sputum ; finally, certain chromogenic bacteria may 
explain the color. . 

Among the other appearances of the sputum may be mentioned the 
black sputum of anthracosis, found especially in coal-miners, but to 
a lesser degree in all city residents. The sputum is stained by the 
particles of inhaled coal-dust. Some insist that it is only the dust en 
route to the lung which is gathered by the phagocytic cells and expec- 
torated, hence should the person move to a locality without that dust 
the sputum would soon be free, no matter how loaded the lymphatic 
channels of the lung might be, and a return or continuance of the 
pigmented sputum would mean the presence of a destructive process. 
Yet some coal-miners without any suspicion of tuberculosis have black 
sputum for years after they have given up that occupation (Osier). 
Among the other pneumoconioses are siderosis, in which the sputum 
is stained red with the ferric oxide inhaled by mirror polishers ; work- 
ers in brass and bronze have a sputum stained by metal ; those inhal- 
ing mineral dust suffer from chalicosis, " stone-cutters' phthisis," 
" grinders' rot," and expectorate much of that dust; this condition is 
common among the stone-hewers who work with sandstone, and hence 
cases are frequent in the Strassburg clinic. The chest is retracted, 
since the large amount of dust leads to malnutrition of the lung. In- 
fection of the lung is easy, local gangrene even with pneumothorax 
may result. They may give a long history of haemoptysis without 
tuberculosis, but sooner or later all become tuberculous. Workers 
with ultramarine blue or methylene blue, or similar dye-powders, have 
deeply stained sputum. Millers and bakers expectorate doughy masses, 
and the sputum of cotton-mill operatives is often full of that fibre. 

The observer must not be deceived by various vegetable or animal 
fibres, or by food or drink mixed with the sputum. Milk, eggs, wines, 
coffee, chocolate, tobacco, licorice, and various medicines can confuse 
one. 

Finally, chromogenic bacteria may change much the appearance of 
sputum, especially in summer, — e.g., bacillus virescens, pyocyaneus, 
and many others. Sometimes in a " sputum cup ward infection" the 
cups in a series may show the presence of these organisms. The 
sputum when expectorated will of course not be thus colored. 

1 Gesam. Beitr., ii. p. 699, 1871. 



22 



CLINICAL DIAGNOSIS 



Air is present in the sputum in various amounts and in bubbles of 
various sizes. From the size of the air-bubbles can in a general way 
be determined the size of the bronchi in which the sputum was formed, 
and the effort required to expel it. Sputum from cavities and large 
bronchi contains no air, and hence sinks in water. This " sputum 
fundum petens" was formerly given an overrated diagnostic value, 
since it was supposed to indicate a cavity. 

The layer formation of sputum is of value. In certain conditions, 
especially bronchorrhcea, bronchiectasis, putrid bronchitis, and gan- 
grene of the lung, the sputum is abundant, and in a tall jar will sepa- 
rate into three layers, — an upper of frothy mucus, a lower of morpho- 
logical elements, pus, tissue shreds, detritus ; and a middle of the pus 
serum, usually an opaque watery fluid. Often a fourth layer just 
under the mucus consists of the material of the sediment and hangs in 
long shreds down through the pus-serum. 

Odor. — Ordinarily the sputum when fresh has almost no odor. 
Sputum allowed to stand, or that which has stagnated in the body, 
soon gains, or has when expectorated, a very positive odor; that of 
tuberculosis and bronchiectasis is heavy, sweet, and penetrating; that 
of a perforating empyema is said to resemble old cheese ; that of putrid 
bronchitis and many cases of bronchiectasis is fetid ; that of gangrene 
is usually the worst of all. The odor of the breath has some im- 
portance, especially in tuberculosis, for it may be fouler than the 
sputum in the cup, perhaps owing to the fact that the warm sputum in 
the body scents the air more than when cold, in which case it may be 
odorless. Some have claimed to have diagnosed small cavities by this 
sign before they could have been discovered by physical examination. 

Macroscopic Constituents. — Small masses of pus are common, 
whose size indicates, to a certain degree, the size of the bronchi from 
which they arise. 

Fragments of necrotic tissue occur, sometimes large in abscess 
and gangrene of the lung, but small in tuberculosis in which disease 
large masses are rare except perhaps from the wall of a cavity around 
which is such active proliferation of connective tissue that the necrotic 
tissue is dissecting free. The great majority of the fragments are 
almost at the limit of gross vision. The fragments from an abscess 
are permeated by pus-cells, hence are yellow in color ; those from other 
conditions are dark from changed blood, while the smaller ones are 
black, often from coal pigment. The recognition of even the smallest 
is important, since in them one has the best chance of finding elastic 
tissue. 

If the sputum be squeezed out between two plates, these small frag- 
ments can be seen as yellowish, often pigmented threads, for the most 
part just on the limit of vision while some are even 2 cm. long; or 



THE SPUTUM 



2:] 



as masses from those very minute to those the size of a pea. The 
search is much facilitated by a small hand-lens. They are found in 
the greatest numbers in the nummular masses from a tuberculous 
cavity. Necrotic fragments of cartilage from tuberculous ulcers of 
larynx, trachea, or bronchi are sometimes found. Tumor fragments 
should be looked for. 

Dittrich's plugs are bodies of considerable interest. They are 
sausage-shaped casts of bronchi, varying in size from very small to 
those the size of a bean, but the majority from that of a millet- to a 
mustard-seed. The smaller are of an opaque yellowish-white, the 
larger of a dirty gray color. If crushed between the fingers they are 
found to have a horrible stinking odor. Microscopically, they consist 
for the most part of zooglcea of bacteria, fatty acid crystals, fat drop- 
lets, and cell detritus. Few cells are contained, except in some a few 
leucocytes indicating perhaps that the plug is fresh. Pigment granules, 
fragmented red corpuscles, hsematoidin crystals, flagellates, and a lep- 
tothrix taking a fine blue with iodine solution and not yet well studied, 
have been found. The fatty acid crystals of the larger plugs are long 
and curved, while those of the shorter are fine needles. These plugs 
occur in any putrid disease, especially putrid bronchitis and bronchiec- 
tasis, in which case they are especially large. How these are formed we 
do not know (Hoffmann). Similar plugs are derived from the crypts 
of the normal tonsils, and especially in case of follicular tonsillitis. 
These are of beech-nut shape. 

Curschmann's spirals are perhaps the most beautiful structures 
found in the sputum. They occur at some time in practically every 
case of true bronchial asthma, and have been reported present in acute 




Fig. 1. — A spiral thread of mucus from the sputum, x 5. 

bronchitis, acute lobar pneumonia, chronic pulmonary tuberculosis, and 
in rare interesting cases which seem to stand between bronchial asthma 
and fibrinous bronchitis, in which are expectorated small fibrinous casts 
with a few typical spirals directly continuous with the tips of their 
branches. Curschmann considered the spirals due to a bronchiolitis 
exudativa. (For a description of these spirals, see page 64). In some 



24 



CLINICAL DIAGNOSIS 



sputa coarse strands of mucus and pus may be twisted into a spiral 
shape (see Fig. i ). 

Fibrinous Structures. — Under this head we include all struc- 
tures ordinarily thus termed, although in some the presence of fibrin 
is rather doubtful. 

The pseudomembranous casts of diphtheria are sometimes present 
in the sputum. If from the throat, larynx, or trachea, they are in un- 
formed masses, but if from the bronchi, may form arborescent casts, 
from the size of which may easily be judged the extent of the process. 
These are whitish in color and contain many epithelial cells. In pneu- 
monia casts of smaller bronchi are found very often if one takes the 
trouble to search for them (see page 58). These are more brownish or 
reddish, and contain blood and many leucocytes. The most beautiful 
casts occur in the chronic idiopathic fibrinous bronchitis (see page 72). 
Acute fibrinous bronchitis accompanies various fevers, typhoid, ery- 
sipelas, measles, smallpox, scarlet fever, acute articular rheumatism, 
also exophthalmic goitre, pulmonary tuberculosis, mitral disease; in 
the rare albuminous expectoration after thoracentesis, and after the 
inhalation of irritating vapors and gases, similar casts have been 
found. Bettmann 2 gives a good review of the subject. 

In addition to well-formed arborescent casts occur unformed 
masses of similar nature, evidently also from the bronchi. These were 
perhaps expectorated before a definite cast could be formed. 

That much of this material is fibrin is very doubtful. The tests 
generally applied are; the physical properties of the mass (color, tough- 
ness, etc.), the fact that it swells and clears in acetic acid (which pre- 
cipitates mucin), and the rapid effervescence on the addition of hydro- 
gen peroxide. Hirschkowitz, in one from a case of tuberculosis, found 
only fibrin present. 

Casts formed of the mycelium of fungi have been found. In 
Osier's case the small cast consisted of the mycelium of some form 
of the aspergillus. Casts due to a similar parasite were expectorated 
for years by the case reported by Devillers and Renon. 3 

Lung Stones. — This name is applied to almost anything having 
the appearance or consistency of a stone. Theoretically, they could be 
cartilaginous, osseous, or calcareous, but to the last alone is the term 
strictly applicable. 

Enchondromata and osteomata of the bronchi and lungs are found 
at autopsy, but among Poulalion's cases (These, Paris, 1891) we 
could find mention of none in which they were expectorated. Neither 
do we know of any case in which the stone has arisen in a calcified in- 
farct, nodule of bronchopneumonia, miliary abscess, pseudotubercle of 

2 Am. Jour. Med. Sci., February, 1902. 

3 La Presse Med., 1899. 



THE SPUTUM 



25 



actinomycosis, cladothrix, or moulds, nor from the calcified wall or 
contents of a cyst or tumor, although at autopsy such concretions are 
found. Frankel mentions one case in which the stone was a fragment 
of the bronchial cartilage which had become calcified and then dis- 
sected free, and Hoffmann one of a calcified blood-clot. 

But in the vast majority of cases lung stones are calcified tuber- 
culous material. These have been classified in two groups, bronchio- 
liths and pneumoliths. 

The Bronchioliths are formed by the deposit of salts in the stag- 
nated contents of a bronchus or bronchiectatic cavity. They may be 
from smaller or larger bronchi. One would expect them to be arbo- 
rescent, but for the most part they are irregular, jagged, from the size 
of a millet-seed to a bean. They may be chalky or stony hard. As a 
rule, they are single or at most two or three in number, but sometimes 
several hundreds. Poulalion suspects that these great numbers are 
fragments of larger stones. Some " resembling coral, finely ramified, 
and very hard " have been described. In one case the stone weighed 
0.47 gm. and had ten or twelve branches. In Atlee's case 4 the stone 
was three-quarters of an inch long and one-quarter of an inch wide at 
the larger end. 

Pneumoliths may be calcified caseous areas, which, treated as for- 
eign bodies, ulcerate into a bronchus, or the contents of a closed 
cavity which become impregnated with lime salts and then set free. 
Another source, perhaps a common one especially in those cases in 
which the lung parenchyma was normal, are the calcified bronchial 
lymph glands. Of the pneumoliths, there are two distinct varieties, — 
the cretaceous, which are chalky in consistency, and the calcareous, 
which as a rule are small and hard, and have a rough, rounded surface. 
Their size varies from that of a millet-seed to a pigeon's egg. 

Chemically lung stones consist of calcium and magnesium as bases 
with carbonic, phosphoric, and sulphuric acids, also traces of ferric 
oxide and other metals. Their composition varies; in some, one or 
another salt predominating in a large mixture, while others seem com- 
posed of but one calcium salt. 5 Unless the stone is branched, or in it 
can be found tissue structure, one cannot state definitely what its source 
was. Cases which expectorate any stones usually expectorate them iri 
such numbers, even 200 and in one case 500, that the name " pseudo- 
phthisis calculosa " was formerly given to the condition. To explain 
these cases Hoffmann and others consider it necessary to assume a con- 
stitutional abnormality, an increased excretion of lime salts through the 
lungs. In these the " haemoptysis calculosa " is often a feature of the 

4 Am. Jour. Med. Sci., vol. cxxii., 1901. 

5 See Stern, Deutsch. med. Wochnschr., 1904, No. 39; Carlyon, Brit. Med. Jour., 
1890, ii. p. 1474. 



26 



CLINICAL DIAGNOSIS 



" bronchial colic" accompanying the expulsion of the stone, and is due 
to trauma of the mucosa; while usually not abundant it may be ex- 
treme. Abscess, gangrene, or pneumothorax may result from the 
presence of these stones. Some concretions have a foreign body as a 
nucleus, a cherry-stone or a grain of wheat. In others the lung-tissue 
impregnated with the salts remains, and when decalcified the structure 
of the lung, even with some few remaining nuclei, may be seen in the 
sections, and the tubercle bacilli demonstrated. 

Among foreign bodies expectorated may be mentioned teeth, 
cherry-stones, and coins. 

Fragments of the wall of echinococcus cysts or the daughter cysts 
themselves may be expectorated. 




l 



Fig. 2. — Extraneous matter common in the sputum. Threads of, A, linen; B, silk; C, cotton; D, 
wool ; E, starch granules; F, guard cells from a lettuce leaf ; G, squamous epithelium from tongue, with 
bacteria attached ; H, tobacco, showing the surface of the leaf, the large cells stored with oil, and a spine 
from the surface. X 200. 

Microscopical Examination. — The microscopical examination of 
the fresh sputum is easy, valuable often, but very much neglected. The 
technique is of course simple. A little sputum is spread upon a plate, 
the base of which is half black, half white, and the interesting particles 
chosen and squeezed between the cover glass and the slide. Thin 
specimens are essential. The first point of importance is that the ob- 
server recognize at a glance the extraneous structures, and these 
are many in number. Among them may be mentioned almost any of 
the food-stuffs, but particularly fragments of bread, bits of orange- 
pulp or other fruits, drops of milk, portions of jams and preserves, the 
skin of fruits, portions of tobacco, etc., portions of meat in which is 
elastic tissue, and fragments of vegetable leaves. In addition, it is 
important to recognize various threads, particularly fibres of linen, 
cotton, wool, and silk, and small fragments of paper (see Fig. 2). 



THE SPUTUM 



27 



Pus-cells. — Thin smears of sputum may be treated like blood 
smears and stained with the same stains, especially the methylene blue- 
eosin mixtures. 

The pus-cells are usually polymorphonuclear neutrophiles. They 
are spherical in shape, of from 7 to 10 microns in diameter. These 
granular cells are often filled also with fat globules or pigment gran- 
ules ; in some glycogen may be demonstrated. In asthma the eosino- 
philic cells usually predominate, and one may search long for any other 
form. There is a form of bronchitis which has been known as 
" eosinophilic bronchitis," since so many eosinophiles are present in the 
sputum. Hilderbrandt 6 holds that their presence speaks neither in 
favor of asthma nor against tuberculosis. 

The various epithelial cells are important. Since these come 
from several sources, many forms may be expected and their origin 
should be recognized. Pavement epithelium may come from the mouth, 
the pharynx, and the respiratory tract as low as the vocal cords. It is 
a very valuable lesson for the student to scrape from the surface of the 
tongue by means of a cover-glass a little of the superficial epithelium 
and study the masses of epithelium covering the villi, to which are 
attached large zooglcea of bacteria. Cylindrical epithelium may come 
from the nose or bronchial tree. While the cylindrical epithelium cells 
from the trachea and bronchi are both goblet and ciliated in the 
sputum, the majority soon lose their original shape and can merely be 
recognized as cylindrical cells. These occur early in bronchial catarrh, 
and later are replaced by pus-cells. It is seldom that cells which are 
actually ciliated are seen in the sputum except in asthma, ulcerative 
processes, and recent bronchitis. In a recent case of asthma small 
clumps and a rather large sheet of cylindrical epithelium were found. 

The alveolar epithelial cells it is important to study. They 
are present in considerable number in nearly every sputum examined, 
even in that of normal persons, and they may assume a large variety 
of forms, some of which it is very difficult to recognize. Every 
observer is pretty certain to be deceived once or oftener by these cells. 
In general, they may be said to be from four to five times the size of 
a leucocyte, oval, with a coarsely granular protoplasm and one or more 
large, oval, vesicular nuclei. They are found in normal sputa, as well 
as in almost every other condition. Their large number in bron- 
chitis would indicate some intimate pathological relation between the 
bronchi and the alveoli. They occur in largest numbers in the sputum 
of patients with inflammatory processes in the lungs, especially tuber- 
culosis. In some of the tuberculosis cases, however, although these cells 
may fill the alveoli they may not be found in the sputum. These cells are 



6 Munch, med. Wochnschr., 1904, No. 3. 



28 



CLINICAL DIAGNOSIS 



amoeboid on the warm stage, and would seem to be important phago- 
cytes in the lung. Formerly their origin was disputed, but now it is 
agreed that they arise in the alveoli. 7 The inclusions of these cells 
are many. Coal pigment (see Fig. 3, a) explains the black granules 
present in all morning sputa of even normal persons, representing 
the inhaled dust of the day before. The origin of these black granules 
was long in dispute, until in one cell was found a granule in which 
the structure of wood was unmistakable. This patient had evidently 
inhaled charcoal dust. These pigmented cells are often present in 
large numbers, and give the sputum a smoky, grayish, or dirty green 
color. When present in large numbers in certain diseased conditions, 
the old term " phthisis melanotica" was applied. Some of these alveo- 
lar cells are rilled with smaller or larger, very refractile, round, fat 
globules (see Fig. 3, i). Myelin globules are irregular in shape, not 
perfectly spherical, often presenting concentric lines, with very little 
refractivity, and of a dull greenish or blue appearance. They may 
be few in number or fine, filling the cell ; or one may occupy the most 
of the cell (see Fig. 3, h). Some think these represent the products 
of degenerated protoplasm ; others that they are a normal secretion 
of the bronchial mucosa which these phagocytes accumulate ; 8 others 
that they arise from the goblet-cells, but the absence of the free 
granules in the nasal and pharyngeal mucus speaks against this. 
When large groups of these cells are present, as in normal' morning 
sputa, in some cases of bronchitis, acute or chronic influenza, and 
sometimes pneumonia during resolution, and especially the " desqua- 
matory catarrhal pneumonia," the sputum contains small lumps 
markedly resembling boiled sago, hence the name " sago granules." 
Free myelin may occur in large amounts as sharply defined, palely 
refractive drops of very different sizes and peculiar shapes (see Fig. 
3, /). It was to these, from their resemblance to the myelin globules 
of nerve-tissue, that Virchow gave the name " myelin drops." While 
the term " myelin" carries with it no hint of the chemical nature of 
the droplets which are seen in the sputum, urine, stools, or nervous 
tissue, since substances of very various nature — fatty acids, oils, neu- 
tral fats — can give droplets of just this appearance (Liebreich), F. 
Miiller and his students think that those of the sputum consist chiefly 
of protagon, with some cholesterin and lecithin. They swell some- 
what in water, are not destroyed at ioo° C, are stained yellow by 
iodine, stain poorly with aniline dyes, do not turn black with osmic 
acid, are easily soluble in alcohol, slightly in ether and chloroform. 
The amount of myelin in the morning sputum may be so great that 
it seems to surpass that of the mucus. To a certain extent the excre- 

7 See Hoffmann, Nothnagel's System, Die Krank. der Bronchien. 

8 See Schmidt, Berl. klin. Wochenschr., January 24, 1897. 



J 



b 



A 




Fig. 3.— Cells in the sputum, a, alveolar epithelium cells containing coal-dust ; d, squamous epithe- 
lium cell; d, cylindrical epithelial cell ; e and f, Herzfehlerzellen ; g, cells showing a peculiar degener- 
ation ; A, those with myelin droplets; t, one full of fat droplets; j, free myelin; k, red blood-cells; /, 
bacteria ; m, free blood pigment. X 400. 



THE SPUTUM 



29 



tion of these two bodies runs parallel. Myelin globules present a 
variety of shapes ; concentric spheres or club-shaped masses, small 
globules or by confluence of small globules, larger drops (see Fig. 3, 
/). On standing their number and size are greatly increased. The 
alveolar cells containing derivatives of haemoglobin are of particular 
interest. The haemoglobin, certainly derived from the red blood-cells 
of the sputum, may be present in amorphous granules or scales of a 
brownish color, or haematoid crystals. " Herzfehlerzellen " (see Fig. 
3, f) is the name given to these cells filled with a golden yellow pig- 
ment, when they occur in large numbers, and over a long period of time ; 
only then have they any diagnostic importance. The granules are 
sometimes small but often large. They have a translucent appearance, 
are not opaque, and certain cells seem to be diffusely stained. Since 
these granules are not opaque or deeply colored, but seem only tinged 
yellow, the student at first is disappointed in their appearance. In 
chronic passive congestion, especially that due to mitral disease, these 
cells may give a gross color to the sputum, the entire mass being of a 
rusty color ; or, what is more common, they are clustered into dots and 
streaks of a reddish-brown color in a white mucous background. They 
occur also in all other conditions in which red blood-cells escape into 
the alveoli, namely in pneumonia, infarction of the lung, and after 
pulmonary hemorrhage. 

The red blood-cells (see Fig. 3, k) in the sputum are often well 
preserved, yet not always, as is seen by the masses of amorphous 
haemoglobin and by the inclusions of the alveolar cells. They are 
crowded into lines and masses, allowing nothing of their shape to 
be seen, and are recognizable only by their color. They are sometimes 
squeezed out into long threads. In judging the importance of blood 
in the sputum, however, even macroscopically, it is well to bear in 
mind the numerous sources it may have had; for instance, the nose, 
the mouth, and the pharynx. 

Elastic tissue is a most important body. Formerly its presence 
was of greater importance, and before the discovery of the tubercle 
bacillus was the best evidence of consumption. Even now it is of 
considerable value, since its presence indicates certainly destruction of 
the lung, and in some cases it is found before the tubercle bacilli, but 
perhaps not before they are present. The masses of elastic tissue are 
usually almost on the limit of vision with the unaided eye. This is 
particularly true in tuberculosis, in which molecular disintegration is 
the rule, although in some cases only single fibres may be found. The 
Sir Andrew Clark method is the one which Dr. Osier recommends, 
as by its use the various methods of destroying other tissue, such as 
boiling with sodium hydroxide, etc., may be dispensed with. For this 
two glass plates are used, — the one about fourteen and the other six 



30 



CLIXICAL DIAGNOSIS 



inches square. The sputum is poured on the larger plate, pressed out 
by the smaller. The plate should rest on a dark background. With 
a small hand-lens fragments of tissue may be easily selected, and then 




Fig. 4. — Elastic tissue from lung. X 400. 



after sliding the upper glass away from them they can be picked up 
with a needle. These appear as small grayish-yellow spots. In some 
cases it is not necessary to remove them for inspection with the higher 
power, since a small pocket-lens will be sufficient. Others prefer 
Petri's dishes, or wooden boxes with black base, or crockery plates with 
the base half black, half white. One must be very careful not alone 
to sterilize this glassware, but to wash it well in chemicals which will 




Fig. 5. — Elastic tissue from lung showing alveolar arrangement. X 50. 



destroy all organic matter (a saturated potassium bichromate solu- 
tion in concentrated sulphuric acid is recommended), else there is 
chance that the bacilli found may not be from the sputum in question. 
Particles of food will confuse the beginner. Under the cover-glass 
small fragments of elastic tissue may be found with the low power of 
the microscope. Larger fragments of lung-tissue are sometimes 
present. When no fragments are found in this way, a search with 
the higher power must be made for single fibres of elastic tissue, in 
which case it is well to select the grayish masses of sputum from the 



THE SPUTUM 



31 



tuberculous cavity, or the grass-green or slightly rusty particles which 
are present in the sputum of subacute caseous pneumonia. The fresh 
specimens must be very thin and the cover well pressed down, or the 
fibres may be overlooked. 

The elastic tissue from the lung may be present in three arrange- 
ments, depending on its source : fibres from the alveolar walls may 
preserve the outline of one or several alveoli (see Figs. 4, 5), and are 
long and branching; the fibres from the bronchial walls occur singly 
or in small groups, are often fragmented, and often present what 
Dr. Osier considers the most characteristic picture, two or three long- 
narrow fibres clustered closely together in an elongated net-work ; from 
the arteries may arise a distinct sheeting. Fragments containing a 
coarse net-work of short interwoven fibres are seen from ulcers of 
the larynx. 

When the elastic tissue is very small in amount it is customary to 
destroy all other tissue by means of potassium hydrate, but if the above 
Clark method be carefully used this method is not necessary. Ten 
cc. of sputum are mixed with an equal amount of 5 to 10 per cent. 
KOH or NaOH ; the mixture is then boiled in a porcelain dish until 
the mass is homogeneous. About four volumes of water are then 
added, the entire mass shaken up and centrifugalized. Nothing is 
left but the elastic tissue. The fibres, however, have lost their 
characteristic appearance, being now paler and swollen. 

The fibres of elastic tissue (see Fig. 4) even when single should be 
recognized. They are characterized by their intense refractivity, their 
wavy outline, their sharp edges, their uniform diameter, and their 
curling ends. They often branch. They are insoluble in ether, potas- 
sium hydroxide, and on warming. Pressure does not cause any 
varicosities. Their appearance is very characteristic with the low 
power, perhaps more so than with the higher, although the latter should 
always confirm the former. In the thin specimen they will stand out 
as very distinct, coarse, sharp, blackish fibres. It is necessary to ex- 
clude fibrous tissue, fatty acid crystals (see Fig. 6), bacteria, and 
vegetable cells and fibres. The fibrous tissue fibres are very different 
in appearance, being present in bundles of fine wavy lines without the 
coarse black refractive appearance of elastic tissue. (For the fatty 
acid crystals, see page 33.) The chains of bacteria are very con- 
fusing, especially certain leptothrix forms (see Fig. 7). These are 
found in the fresh sputum, but especially that which has stood for some 
time. The long chains will sometimes present a beautiful interlaced 
net- work and sometimes simulate closely the framework of an alveo- 
lus. Under the high power, however, it will be seen that these fibres 
are chains of bacilli. They differ also in size and in refractivity and 
in the absence of the wavy outline. They are also much more crowded 



32 



CLINICAL DIAGNOSIS 



in the field than is elastic tissue. Vegetable cells and fibres are much 
coarser and should not confuse. The elastic tissue from food is often 




fiG. 6. — Fatly acid crystals resembling elastic tissue in the sputum of a case of bronchiectasis. X 400. 




ic tissue. X 400. 



coarser and of more irregular outline (see Fig. 8). Moulds should 
be easily recognized (see page 37). 



THE SPUTUM 



33 



The presence of elastic tissue is the surest sign of disintegration of 
the lung. About 90 per cent, of the cases are of tuberculosis. In this 
disease it has a certain prognostic value, since as the healing process 
begins it becomes scarce and then finally disappears. Its constant pres- 
ence means an advancing disease. In tuberculosis it is present usually 
in minute particles. In gangrene of the lung it can almost always be 
found despite the old idea which attributed a certain diagnostic im- 
portance to its absence. It was then supposed to be digested by a 
ferment, but Dr. Osier states that he has never seen a case without it, 




Fig. 8.— Elastic tissue from saliva ; origin, the food. X 400. 



and usually in large fragments. It is also found in cases of lung ab- 
scess, of liver abscess perforating through the lung, and finally in frag- 
ments of tumors. 

Crystals are present only in sputum which has stagnated in the 
body for a long time or stood in the cup. They occur chiefly there- 
fore in putrid bronchitis, bronchiectasis, tuberculosis, and gangrene. 
Fatty acid crystals occur either singly or in rosettes, short or long. 
They usually are found in clusters in a mass of detritus. When very 
long they may simulate elastic tissue (see Fig. 6), but they are usu- 
ally relatively thick, with stiff curves and pointed ends. If pressure 
is made on the cover-glass, varicosities will result. They are soluble 
in potassium hydroxide and in ether. (The specimen should be dried 



34 



CLINICAL DIAGNOSIS 



before the ether is added.) If the slide be warmed, the crystals will 
disappear and fat droplets take their place. It is necessary to exclude 
elastic tissue and chains of bacilli. Cholesterin crystals are rare; they 
occur usually in company with fatty acid crystals. Tyrosin and leucin 
occur chiefly in putrid sputum which has decomposed in the air-pas- 
sages. If the sputum be evaporated in the air, the crystals will separate 
out. In the case of abscess of the lung they are sometimes found in 
the first discharge, not later. Tyrosin is present as sheaves of long 
black refractive needles. The spherules of leucin, which perhaps never 
occurs without tyrosin, are more seldom found unless the sputum be 
evaporated. It is necessary to exclude soap globules (see page 391). 
Triple phosphate and calcium oxalate crystals occur in the same con- 
ditions. The rhombs or the needles of hmnatoidin occur especially in 
abscess of the lung, perforating empyema, or a liver abscess perforating 
through the lung. They are found seldom after hemorrhage, for 
in this condition the haemoglobin is changed to amorphous granules. 
For figures of these crystals, see chapter on Urine. 

The Charcot-Leyden crystals (see Fig. 67) resemble a diamond 
very much elongated, or, to use the description of one, two very sharp 
pyramids with the bases together. They have sharp, elongated points 
with clear-cut edges, colorless, with very little yellow refractivity. 
They are brittle, hence easily broken in making the specimen. They 
vary greatly 'in size, some requiring the oil immersion lens, while the 
largest are 0.075 mm - long" an d 0.04 mm. wide. They stain with 
eosin, are soluble in hot water, mineral acids, and the alkalies. They 
occur singly or in groups, in which latter case they may form clusters. 
In these groups it was noted that on cross-section they were hexagonal, 
and therefore are not octahedral crystals, as was formerly supposed. 9 
Other forms, for instance a Greek cross, may occur but rarely. That 
they belong to the hexagonal system is very sure proof that they are 
not the Bottcher spermin crystals. Their appearance had identified 
them with these, but the similarity is only superficial, and the proof that 
they belong to a different crystal system rules out this identity, hence 
there is no reason for supposing they consist of spermin. They are 
quite certainly derived from eosinophile cells, but how is uncertain. 
They occur wherever these cells are increased, especially when the 
sputum has been stagnant, and increase in the sputum after expectora- 
tion if it be placed within the thermostat. They occur, therefore, in 
the largest numbers in the sputum of asthma, in which case 60 per cent, 
or more of the leucocytes may be eosinophils. According to a former 
idea, it was the irritation of these sharp crystals which provoked the 
asthmatic paroxysms. In this condition they occur chiefly in connec- 
tion with the Curschmann spirals. They occur, however, in other con- 
8 Cohn, Deut. Arch. f. klin. Med., 1895, liv. 515. 



THE SPUTUM 



35 



ditions than asthma, and while some claim that in this disease they are 
not always present, others have found them in every case in which they 
have searched for them. 

Plant Parasites. — The bacteria present in large numbers in the 
sputum are, with the exception of a few specific germs, as of tubercu- 
losis, whooping-cough, influenza, pneumonia, and a few others, chiefly 
saprophytes which are added in the mouth, or by the cup or air after 
expectoration, and which increase enormously in the sputum on stand- 
ing. In other cases these harmless organisms live in the respiratory 
passages, as in bronchitis, and especially in bronchiectatic and tuber- 
culous cavities. These are simply saprophytes, and if they have any 
effect it is only to aid in the decomposition of the sputum. These 
masses of saprophytes sometimes deceive a student, since he suspects 
some specific germ when he sees a large epithelial cell full of small 
diplococci, or zooglcea of bacilli. The chromogenic bacteria are of 
importance macroscopically rather than microscopically, as during 
the warm months they may entirely change the color of the sputum 
after it has been expectorated. Interesting ward infections, that is, 
infections of the cups which pass from bed to bed, sometimes occur. 
Streptococci and staphylococci and other truly pathogenic organisms 
are found in large quantities in certain diseases, and may, in tubercu- 
losis, aid in the destructive process of the lung. 

Streptothrix Pseudo-Tuberculosa. 10 — This streptothrix was 
found in the lungs of a patient with extensive consolidation of both 
lungs, but who clinically had had no sputum. The symptoms were 
generally those of pulmonary tuberculosis. Warthin and Olney 11 
collected a group of five such cases, including their own, with, they 
think, the same organism (Streptothrix eppingeri) in the sputum. This 
organism has true branching threads occurring in large entangled 
masses, even grossly visible as minute grayish granules in a white, 
homogeneous, not bloody sputum. Some of the filaments are very long 
(even several oil-immersion fields), with short branches and without 
club-shaped ends. They are about four times as thick as the tubercle 
bacillus. They are acid-fast, staining with a beaded appearance, but 
are slowly decolorized by 95 per cent, alcohol. They stain by 
Gram's method. 

The leptothrix group of normal mouth organisms flourishes in 
abundance in the lungs, especially in putrid gangrenous disease. Their 
probable effect is to aid in the decomposition of the sputum. Miller has 
separated from the old group of " Leptothrix buccalis," Leptothrix 
innominata, an organism unsegmented, straight, but sometimes wavy, 
from 0.5 to 0.8 micron broad, which occurs always in the tartar of 

10 Flexner, Johns Hopkins Hosp. Bull., June, 1897. 

11 Am. Jour. Med. Sci., 1904, cxxviii. 



36 



CLINICAL DIAGNOSIS 



teeth. This cannot be cultivated, and with iodine solution stains a pale 
yellow. Bacillus buccalis maximus is an organism occurring in single 
threads or in bunches of parallel threads, the single organisms from 
30 to 150 microns long and 1 to 1.3 microns broad, joined into long 
threads. These cannot be cultivated and take a deep blue with iodine. 
Leptothrix maximus buccalis, a somewhat longer parasite than the 
last mentioned, but otherwise similar except it does not give the iodine 
reaction. 

The micrococcus tetragenus is a parasite occurring always in 
groups of four in a mucous capsule, each organism about 1 micron in 
diameter. It is a pyogenic parasite which occurs in the sputum in 
bronchitis, in tuberculous cavities, and hemorrhagic infarctions. It 
may aid the tubercle bacillus in its destructive processes. To recognize 
the pathogenic form it must be cultivated, for there is in the mouth of 
normal persons a harmless parasite of exactly the same appearance, 
which, however, cannot be cultivated. 

Sarctn^e are rare in the sputum, and when they do occur are prob- 
ably harmless saprophytes. They occur chiefly in gangrene, tubercu- 
losis, bronchitis (see page 70), pneumonia, and in the sputum of old 
debilitated persons. They are the cause of the gray patches of 
stomato-pharyngomycosis sarcinica. Whether this parasite is the 
same as the sarcina ventriculi or not is a disputed point. 

Yeasts occur but rarely are recognized. Fresh sputum must be 
examined. They are usually accidentally present, since, although uni- 
versal, they flourish only in the fluids suitable for them, and in man 
these fluids are rare excepting the urine of diabetes and the gastric 
juice in certain cases of dilatation. They occur often enough, how- 
ever, and should not be overlooked or unrecognized. They are oval or 
elliptical cells (see Fig. 64), rarely spherical, so refractive that they 
may resemble a fat droplet so markedly that chemical reactions are 
necessary to differentiate the two. Their size varies from 1 to 40 
microns in diameter, although of each yeast there is a recognizable 
average size. Their appearance varies, in some cases being naked cells, 
in others with a membrane, or a membrane and vacuoles, according to 
the age of the cell. In some the nucleus is evident even in the fresh 
cell. The characteristic feature of a yeast is its reproduction by 
budding; that is, the projection from any part of the cell of a small 
bud which grows and then constricts off. Although for the most part 
extraneous, the presence in the sputum of certain pathogenic yeasts 
cannot be denied, and in doubtful lung cases they should be looked for. 
Busse 12 has discussed at length his case of " saccharomycosis homi- 
nis," an infection by a pathogenic yeast, " Saccharoiuyces busse," of 
the tibia, resulting in caseous cavities in both lungs in which the yeast 

12 Kolle and Wassermann, Handb. der path. Mikroorg., p. 669. 



THE SPUTUM 



37 



was present. The yeast cells were rather small, about 8 microns as 
an average size although they varied much, very refractive, resem- 
bling fat droplets except with a greenish shimmer. The younger cells 
were homogeneous, but later their membrane and granular protoplasm 
could be clearly seen. They are made clearer by the addition of 
sodium hydroxide. It is possible that did we search for such yeasts 
and not pass them by at once as simple saprophytes, more such in- 
fections could be found among our anomalous lung conditions. 

Moulds are commonly enough found, since the air is simply alive 
with their spores. For their recognition the examination of the fresh 
specimen is indispensable. Many of them are truly pathogenic, and 
it is remarkable that there are not more cases described as primary 
infections. Occurring chiefly in the ear of man, their next seat of 
predilection is the lung. 

These moulds are found only in destructive processes of the lung. 
Whether these " broncho-pneumonomycoses" are primary or secondary 
has been a much disputed point with the weight of evidence at present 
in favor of the primary nature of certain of them. According to the 
former idea (Virchow) they were only secondary, or formed cavities 
in the areas of hemorrhagic infarctions. It is a peculiar thing that the 
cavities containing them are odorless, and there would seem to be an 
antagonism between moulds and the bacteria of decomposition so that 
a cavity filled with the former is protected against the latter, and vice 
versa. Granted a destructive process, these moulds would certainly 
aid and could crowd out the primary organism, hence when examined 
the case will appear to be one of primary mould infection. Recently, 
however, through the work of the French, also of Saxer and others, 
it seems probable that Aspergillus fumigatus can be the primary in- 
vader, causing by necrosis an odorless cavity. Among these moulds 
are : 

( i ) Mucor, of which there are one hundred and thirty varieties, 
six of which are known to be pathogenic. This is a very common air 
form. It is characterized by a much-branched unicellular mycelium, 
which later, however, may have septa; by the form of the sporangia 
which are at the end of erect hyphse, and consist of a columella sur- 
rounded by the spores, the whole enclosed by a membrane. Fig. 9 
represents Mucor mucedo, a very common harmless form. If such a 
mould be found in the sputum, it is well that the observer note care- 
fully the shape of the columella, the size of the spores, and the nature 
of the membrane, although for certain recognition cultures are neces- 
sary. The varieties known to be pathogenic are Mucor corym- 
b i f e r , which is a fine delicate small mould with spores 2 by 3 mi- 
crons in size, the sporangia colorless, pear-shaped, and of a great 
variety of size from 10 to 70 microns; its membrane transparent. 



38 



CLIXICAL DIAGNOSIS 



The columella, evident only when the spores have dropped off, is top- 
shaped the large end distal, and colorless. This form has been found 
perhaps most often in man as the cause of kerato-, oto-, pharyngo-, 
and pneumonomycosis. Mucor r h i z o p o d i f o r m i s, of which 
the sporangia-bearing hyphse are single or branch as in a sheaf, short 
and of a brownish color. The sporangia are globular, when ripe of a 
black color, with an opaque membrane, soluble in water, and columella 
which is brownish, from 50 to 75 microns wide, constricted at the 
base, which is also truncated and with a wide flat apophysis, to the 
margin of which the membrane is attached. The spores are colorless, 
spherical, and from 5 to 6 microns in diameter. Mucor race- 
mo s u s, the spores of which are from 5 to 8 microns long and 4 to 5 
microns wide and round ; the columella elliptical in shape. M ucor 




Fig. 9. — Mucor mucedo. X 60. 

p u s i 1 1 u s , the sporangia of which are black with a thorny mem- 
brane, and from 60 to 80 microns wide; the columella egg-shaped or 
spherical, light brown, from 50 to 60 microns wide ; and the spores 
very small, round, colorless, from 3 to 3.5 microns in diameter. 
Mucor septatus has a pale, grayish-brown, spherical sporan- 
gium, small colorless columellas which after the loss of the spores may 
grow still further. The hyphse have septa, hence the name. The 
spores are about 2.5 microns in diameter. Mucor ramosus, the 
sporangia of which are 70 microns in diameter, black in color, with a 
transparent membrane; the columella round, the spores colorless, 
opaque, from 3 to 4 microns wide and 5 to 6 microns long. 

These forms are known to be pathogenic ; almost all of them have 
been demonstrated in the ear. It is interesting that in all literature only 
four cases are cited in which they have been demonstrated in the lung, 



THE SPUTUM 



39 



and so far as we know in none of these cases were they found in- the 
sputum before death. 

Aspergillus fumigatus (see Fig. 10). This is by far the most im- 
portant pathogenic mould. Its mycelium is a thick mesh of threads 
from 3 to 6 microns wide, the finest without but the oldest with septa. 
The conidia-bearing hyphse are short, club-shaped, and from 8 to io 
microns in diameter at the larger (distal) end. The sterigmata are 
unbranched, from 6 to 1 5 microns long, and are packed together from 
a central point, thus giving a fan-like appearance. The conidia, a chain 
of which is at the end of each of the sterigmata, are round, colorless, 
and from 2.5 to 3 microns in diameter. All parts of this mould have 
a brownish to a dark grayish-green color. The size of the spore 
is important, since those of Aspergillus glaucus are from 7 to 8 



L... zj'/ ^ :.• •- : ^ ^ : 

Fig. 10.— Aspergillus fumigatus. X 3 00 - 

microns in diameter. The spores occur everywhere, as can be demon- 
strated by exposing a moist piece of bread to the air for only a few 
minutes and then placing it in the thermostat. Aspergillus 
f 1 a v 11 s (see Fig. 11), has conidia-bearing hyphae which are from 
7 to 10 microns thick, with the head of a yellowish or green color, 
according to whether it is dry or wet, and brown when old. The 
conidia themselves are round, of a sulphur-yellow color and from 5 to 
7 microns in diameter. Aspergillus n i g e r is of a chocolate 
brown color, and the conidia are from 3.5 to 5 microns in diameter. 
Aspergillus subfuscus is of an olive-green to a black color, 
resembles much the fumigatus, but is more pathogenic. Of these 
forms the Aspergillus fumigatus is the only one that has been shown 
to bear a direct relation to that pathological process known as " pneu- 
monomycosis aspergillina." Sticker "has collected from the literature 



40 



CLINICAL DIAGNOSIS 



twenty cases in which no other disease of the lung was present. Of 
these, in sixteen was found Aspergillus fumigatus, in four cases 
the mould was doubtful. One of these, reported by Osier, was a 
woman who for twelve years had expectorated masses of mycelium the 
size of a bean, grayish and of a downy consistency ; in five cases the 
mould could not be classified. An interesting case of primary chronic 
" membranous" bronchitis due to the Aspergillus fumigatus was 
reported by Devillers and Renon. 13 The patient was a grain-sorter. 
Fragments of membrane composed of the mycelium of this mould 
(recognized from cultures) were expectorated monthly. They were 
from i to 6 cm. long, and, having no branches, probably arose in 
the larger bronchi. In nineteen cases with the Aspergillus fumigatus 
the infection was mixed. Sticker 14 has divided the cases into the 



oo'O 



o 



0 



Fig. ii. — Aspergillus flavus. X 300. 

" sporadic," which are of old feeble subjects or persons suffering 
from a lung disease, and the " endemic," in which case the disease 
is due to the occupation of the patient. The two best illustrations of 
this latter have been described by the French writers. The first con- 
sists of a pseudo-tuberculosis present in pigeon-feeders, who are much 
exposed to the moulds of grain, and hair-combers who work in an 
atmosphere so laden with infected dust that the cat is the only animal 
that can live in their neighborhood. No autopsies have been made on 
such cases. Clinically, the course is often similar to that of a chronic 
pulmonary tuberculosis. At the onset there is hemorrhage in some 
cases, either slight or profuse, and which is generally repeated at in- 
tervals. The cough is dry at first, then accompanied by a frothy 

13 La Presse Med., 1899, ii- P- 325. 

14 Schimmelpilzkrankh. der Lungen., Nothnagel's System, 1900, xiv. 



THE SPUTUM 



41 



sputum which quickly becomes greenish in color and purulent. This 
may continue for months or even years. Blood flecks are often 
present. Toward the end the hemorrhage may recur or not, the 
expectoration is of a greenish color, purulent in nature, and num- 
mular in character. 

Another form is a chronic bronchitis resulting in final cirrhosis 
of the lung. In this case the sputum is abundant, foamy, and watery. 
In Wheaton's case 15 the condition simulated actinomycosis with 
anatomically the presence of a few tubercles and a large cavity. In 
some cases there have been casts of the bronchi formed of mycelium 
and conidia expectorated. 

For diagnosis these moulds must be demonstrated in the sputum, 
and in any case of suspected tuberculosis without the tubercle bacillus 



o 





Fig. 12.— Penicillium glaucum. X 300. 

they should be searched for. There may be present either the myce- 
lium, the conidia hyphae, or the spores. As a rule, they are overlooked 
or passed by as extraneous. The odorless character of the sputum is 
an interesting fact, even in cases of marked gangrene of the lung with 
the expectoration of large masses of lung-tissue. In some cases the 
absence of the mycelial threads may be explained by their destruction, 
which certainly soon occurs. 

The Penicillium glaucum (see Fig. 12), which is the most common 
of our media contaminations, has segmented conidia-bearing hyphse 
which divide brush-like at the end, the branches being tipped by sterig- 
mata which are flask-shaped, bearing conidia from 2 to 3 microns in 
diameter. The refractile conidia of this mould are so common that it 
is strange that the students do not recognize them oftener, particularly 
15 Trans. Path. Soc, Lond., vol. xliv. p. 34. 



42 



CLINICAL DIAGNOSIS 



as some show the characteristic sprouts. The mould is non-patho- 
genic. The Penicillium n u m m u 1 a is certainly pathological 
for animals, and has been found in the ear of man. 

Although the general class, mucor, aspergillus, or penicillium may 
be recognized if the sporangium or the conidia head is found, yet a 
closer differential diagnosis can only be made on cultures. This may 
be done by spreading the sputum over a piece of bread as media, or 
using Sabourand's media (maltose, 3.7; pepton, 0.75; water, 100). 

The moulds may be stained in the fresh specimen by a saturated 
watery solution of saffranin or, better still, of thionin. 

Oidium albicans is the very common parasite of thrush, which 
can develop in the lungs as well as at its common seat, the mouth and 
pharynx. It occurs chiefly in the mouths of children during their 
first week, especially in the weak babies ; more rarely in older children 
or adults weakened by old age or disease, especially diabetes or typhoid 
fever. In these cases we have secondary growths in the throat, nose, 
oesophagus, bronchi, and lungs. The most common form is the large- 
spored variety. It may occur in the sputum in two forms, — the first, 
the yeast-like cells, from 5 to 6 microns long and 4 microns wide, and 
oval, which in shape cannot be told from any other yeast; and the 
threads of all sizes and lengths with a double contour containing 
droplets, granules, vacuoles, but especially conidia-like bodies which 
are true endogenous spores. 

Actinomycosis infection of the human lung is rare. It sets up 
a chronic process, but one which progresses unrelentingly till death. 
In some cases there is a slight catarrhal bronchitis for a long time, 
but the most common form is, from the onset on, a bronchopneumonia. 
The consolidated areas break down forming cavities which contain 
fluid, pus, fatty detritus, fat globules, degenerated red blood-cells, and 
the sulphur granules. Clinically, the picture is of tuberculosis, and 
yet if the sputum be watched carefully an early diagnosis can be made. 
Other cases are of chronic bronchitis, while still other cases present 
the picture of a miliary tuberculosis. The abscess cavities may be very 
large. The sulphur granules are the characteristic find. They are 
small granules, in size varying from microscopic to 2 mm. in diameter, 
of a yellowish, grayish, greenish, or brownish color, round, sometimes 
abundant in number, in other cases, few. Microscopically they are a 
net- work of fine twisted threads, straight or wavy ; at the ends of many 
at the periphery are the characteristic club-shaped swellings which 
when present in large number form a ring around the granule to 
which they give a radiating or star-like appearance. In general it may 
be said that in any case of atypical lung disease always think of this 
(Osier). The expectoration is usually mucopurulent, sometimes fetid. 
It may be simple mucus, very scanty, or may be purulent and hemof- 



THE SPUTUM 



43 



rhagic. It is said that the sputum is sometimes as rusty as in pneu- 
monia. It is also possible that the patient may say that he has ex- 
pectorated at one time a large amount of offensive yellow material. 
Tubercle bacilli will not be found, neither will elastic tissue. 

Animal Parasites. — Infusoria are rare and unimportant. Artault 
described Amoeba pulmonalis as " a small amoeboid cell which when 
dead and stained looks exactly like a leucocyte, but while motile 
differs from it in its refractility and staining qualities." Amoeba coli 
is frequently found in the sputum of cases of liver abscesses which 
have perforated into the lung and in cases of abscess of the jaw com- 
municating with the mouth (Flexner). It is important that the 
student should bear in mind that the same rule obtains here as in the 
examination of the stool, and that nothing should be called an amoeba 
unless its amoeboid motion has been clearly seen. 

Of the flagellata, Trichomonas pulmonalis is the name given to 
a form which has been found several times in the sputum. A. Schmidt 
found them only in the Dittrich's plugs, while Artault found them in 
the contents of a large tuberculous cavity. These may be the forms 
which others have found in lung gangrene and putrid bronchitis. In 
a recent case of large abscess of the lung following pneumonia with 
operation six weeks after the onset of the pneumonia, the sputum 
contained large numbers of these flagellates. It is probably the same 
as Trichomonas vaginalis. Cercomonads have been found in the 
sputum and in the Dittrich's plugs of lung gangrene. 

Echinococcus Disease.— Next to the liver the lung is the most 
common seat of this infection (in 4.5 per cent, of cases) (see Fig. 55). 
If the cyst bursts we may find in the sputum the daughter cysts, sco- 
lices, hooklets, or fragments of membrane, any one of which is char- 
acteristic. They may also be derived from a liver cyst which has 
perforated through the lung. The cyst wall consists of two layers, 
— an external laminated cuticular capsule, and an internal granular 
parenchymatous endocyst. Fragments of this laminated capsule are 
characteristic of the disease. The cyst content is a clear, limpid fluid, 
from 1005 to 1 01 5 specific gravity, which contains no coagulable albu- 
min, is neutral or slightly acid, and contains considerable sodium chlo- 
ride. Inosite, leucin, tyrosin, and succinic acid may be found, also 
hsematoidin. From the endocyst develop buds which grow into smaller 
daughter cysts, and which break loose and lie free in the parent cyst. 
Inside these daughter cysts may develop granddaughter cysts. From 
the inner wall of any of these cysts may develop brood-capsules, cysts 
from the inner or outer wall of which the scolices develop. A scolex 
is the head of a Tinea echinococcus, and presents a rostrum with four 
suckers and a circle of hooklets. If found while alive, the head 
actively protrudes and retracts this rostrum. In many cases the cyst 



CLINICAL DIAGNOSIS 



wall degenerates, becomes inspissated and filled with a cheesy material 
which contains masses of free booklets and dead scolices. The latter 
have a coating of calcium carbonate which effervesces actively on the 
addition of hydrochloric acid. The presence of these cysts may lead to 
gangrene of the lung and the formation of cavities connected with the 
bronchi. Hemorrhages are the rule, usually slight or mere streaking, 
but sometimes profuse. As a rule, such cases are diagnosed as phthisis 
or gangrene, unless one of these characteristic bodies is found in the 
sputum. The cough may at first be dry and hacking, and then as the 
cyst increases in size there may be some mucoid expectoration. If the 
cyst ruptures its cavity becomes infected and the sputum then is fetid 
pus, in some cases of a chocolate color which resembles the pus said to 
be characteristic of hepatic abscess. In other cases the suppuration 
occurs before the rupture and the contents undergo fetid decompo- 
sition; then follow the symptoms of rupture of an abscess. If daugh- 
ter cysts and pieces of membrane are found in the sputum, it means that 
the bronchus communicating with the cyst is a large one. Pieces of the 
membrane may be expectorated for months. The rupture is often 
accompanied by a copious hemorrhage which later may recur. 

Paragonimus Westermanii. — This parasite, the " lung fluke," 
is the cause of the parasitical haemoptysis of man which occurs so com- 



Fig. 13. — Egg of Paragonimus westermanii from the sputum of Dr. Mackenzie's case (through 
the kindness of Dr. Stiles). X 400. 



monly in Japan, parts of China, and Korea. In some mountain towns 
a majority of the people are said to be infected; in Okayama, 0.4 per 
cent, of all hospital cases admitted ; in Kumamoto, 5.9 per cent, of 
pulmonary cases. 16 One case in this country which came under the 
care of Dr. Mackenzie, of Portland, Oregon, has been reported by 
Stiles, — that of a Japanese who recently immigrated. There was 
found in domestic animals in this country, previously, a parasite which 
seems to be identical, and it is perhaps only a matter of time before 
more and endemic cases will be found among our cases of " tubercu- 
losis." The duration of the disease is long, from ten to twenty years 
from the appearance of the first symptom. The diagnosis rests with 

16 Inouye, Zeits. f. klin. Med., 1903, vol. 1, p. 120. 



THE SPUTUM 



45 



the discovery of eggs in the fresh sputum. The sputum is generally 
small in amount, very viscid, and consists of small pellets of blood 
mixed with mucus. In other cases it is as rusty as that of pneumonia. 
When no blood is present the sputum may have any shade of yellow 
and brown, but especially a dark, dirty red or brown, a color due to 
the eggs themselves. Colored spirals resembling grossly the Cursch- 
mann spirals are quite characteristic. The eggs are the only charac- 
teristic symptom, and may be expectorated in large numbers. The 
amount of blood is usually small, at the onset only a few drops, but it 
may be large, from 300 to 800 cc. in a few hours, especially if the 
patient leads a laborious life. There may be rather large hemorrhages 
which recur with great frequency, or the disease may take a very slow 
course. The hemorrhage is always arterial. Its cause is not clear, and 
it seems more accidental than otherwise, since the ova are not in the 
pellets of the blood, but in the rusty portions. The eggs have a thick, 
smooth shell of a dirty reddish-brown color with a characteristic lid 
at one end. In some eggs one does not see the lid, in others it is not 
exactly on the end, and in others it is partly shelled off. They are 
68 to 96 microns long, 48 to 60 microns wide. Charcot-Leyden 
crystals are common in the sputum, " sufficient proof that such crystals 
do not explain asthmatic paroxysms, since these cases never have 
asthma." 17 

Now that a case of this disease has been found in America it is 
very desirable that all be on the watch for more. 

Chemical Examination of the Sputum. — The chemical examination 
of the sputum is seldom of much importance, and those tests which 
have been proposed have as their object to demonstrate the relative 
amounts of mucin and albumin. The Zenoni modification of Schmidt's 
method (Schmidt used the Griibler-Biondi stain) is perhaps the most 
valuable of the muco-chemical tests. Zenoni spreads a small particle 
of the sputum on the cover-glass, treats it with alcohol for at least a 
quarter of an hour, and then stains with a half-saturated water solution 
of safranin. The specimen is examined against a white background. 
The mucus stains yellow, and the albumin red. This method has the 
advantage that when many pus-cells are present, the color of the 
ground substance can be determined microscopically. In pneumonia 
there is much more albumin than in other conditions. 

The chemical test for soluble albumin is simple. The sputum is 
mixed with 3 per cent, acetic acid, shaken well, allowed to stand twelve 
hours, and filtered. The filtrate is tested with potassium ferrocyanide, 
or neutralized, sodium chloride added, and the heat-acid test used. 
Quantitatively it may be estimated by the Esbach tube. In the filtrate 

17 See Stiles and Hassall, Sixteenth Report of the Bureau of Animal Industry, 

1899. 



4.6 



CLINICAL DIAGNOSIS 



of the heat test the albumoses may be precipitated by zinc sulphate, or 
determined by the nitrogen present. Deutero-albumoses alone have 
been found; no peptone (Wanner). Wanner found by far the most 
soluble albumin in the sputum of pneumonia, — 0.3 to 3.6 per cent. ; 
least in that of bronchitis (a mere trace) ; in that of practically normal 
persons the merest trace, if any at all. Its presence means inflamma- 
tion, not hypersecretion alone. Anything more than a faint opal- 
escence is pathological. 

Mucin he determined from the glucosamin formed by adding to a 
weighed amount of sputum two volumes of alcohol, shaking, filtering 
through a hardened filter paper, and washing with alcohol. The pre- 
cipitate is then boiled with 10 per cent. HQ for three hours in a flask 
with return-cooler. The flask is then quickly cooled, made alkaline 
with NaOH, then acid with acetic acid, then precipitated with phos- 
photungstic, to remove the biuret-giving bodies, and the reducing sub- 
stance determined with Fehling's solution (glucosamin having the 
same reducing power as glucose). Pure mucin contains 33.6 per cent, 
glucosamin. 

Much mucin ( 1 to 3.3 per cent.) was found in chronic bronchitis, 
a moderate amount in pneumonia (0.66 to 1.03 per cent.) and phthisis 
(0.74 to 0.79 per cent.), none in bronchiectasis. Sputum is digested 
rapidly by autolysis. 

As to the value of these chemical tests, which are easy and rapid ; 
Wanner considers that a definite trace of albumin in a case of incipient 
tuberculosis or chronic bronchitis will mean the former ; much albumin 
indicates pneumonia or pulmonary oedema, and in a case of either pneu- 
monia or infarction of the lung, the former. 

Peptone in the sputum has been claimed by some, denied by others, 
and a trypsin-like ferment is assumed in gangrene of the lung to ex- 
plain the partial disappearance, perhaps complete in some cases, of 
elastic tissue. 18 

Pulmonary Tuberculosis. — " Pulmonary tuberculosis has no char- 
acteristic form of sputum" (Brown). 

Cases of the fibroid form may have no or little expectoration, and 
this free of tubercle bacilli for a long time. But, as a rule, there is a 
purulent sputum. 

In acute miliary tuberculosis the sputum, if any at all, is that 
of bronchitis, hence mucopurulent or blood-streaked. No tubercle 
bacilli need be present. In the acute pneumonic tuberculosis with 
extensive caseous consolidation there may for one or two months be no 
sputum whatever, but, as a rule, it is that of a typical acute lobar pneu- 
monia, rusty until the crisis should come, and then when one expects 

18 See Wanner, Deutsch. Arch. f. klin. Med., 1902, lxxv. 347; Fr. Miiller, Ztschr. 
f. Biol., Bd. 52. In this is the best discussion of the mucin and allied bodies of the 
sputum. 



TIIK SLTTl'M 



17 



it to change to a mucopurulent a green color may be the first indication 
that there has been a mistake in diagnosis. In a case, therefore, of 
pneumonia with delayed resolution, and especially if the sputum be 
green, search should always be made for tubercle bacilli and elastic 
tissue, for sooner or later they will be present, and sometimes very 
early. 

Among our cases of acute tuberculous lobar pneumonia (fifteen in number), 
in four the sputum was typically rusty. In the majority it was a mixture of a 
rusty with a bronchitic ; in two there was almost no sputum at all. The green 
color and tenacious quality were marked in a few ; in two cases the sputum was 
of a white, sticky, mucopurulent nature from the very first ; one marked feature 
in nearly all cases was the constant blood-streaking, and in two, brisk hemorrhages. 
In the typically rusty sputum very few pus-cells were present, but many alveolar 
epithelial cells and red corpuscles. Later, that is after the first week, the sputum i- 
rather mucopurulent, and yet in many cases it continues blood-streaked. The 
greenish color was marked in several. Later it became nummular, and in two cases 
positively foul. 

In cases with a slight bronchitic sputum which develop tuberculous 
pneumonia the sputum at once changes its nature, becoming tenacious, 
slightly less in amount, and blood-streaked. If a true acute lobar 
pneumonia occurs in the course of a chronic tuberculosis, the sputum 
is that of lobar pneumonia with an admixture of the bronchitic. 

Among our cases the following points were particularly interesting : In one 
the mixture of the rusty and bronchitic sputum expressed itself by the two layers 
in the cup, the upper mucopurulent and blood-tinged, the lower exceedingly tena- 
cious and stringy ; later on it became greenish, purulent, and very tenacious, then 
of a tenacious greenish-gray color, which continued until death a short time later. 
Another case is interesting, since the elastic tissue was found before the tubercle 
bacilli, although repeated examinations for the latter were made. In one case 
diagnosed at first as acute lobar pneumonia, on the third day the sputum was 
markedly blood-tinged, tubercle bacilli were present, and two bronchial casts about 
i mm. in diameter at their larger end were found. In a case with sudden onset 
two days before admission and without previous history the sputum was white, 
sticky, and mucopurulent; this continued with a greenish tinge for nine days, but 
on the nineteenth day there was a sudden marked change, the sputum now abundant 
forming easily two layers, the upper sanguineous, the lower mucopurulent, blood- 
tinged for the first time, and on that day, the nineteenth, the tubercle bacilli were 
first found, although they had been repeatedly searched for. 

In the acute tuberculous bronchopneumonia a hemorrhage 
is sometimes the first symptom. The sputum may early show elastic 
tissue and tubercle bacilli. 

In the chronic ulcerative tuberculosis, the sputum may 
assume almost any color or any form assumed in any other disease. 
Biermer divided it into four forms ; the mucoid, mucopurulent, blood- 
stained, and pure blood. It may vary in amount from nothing to one 
litre in twenty-four hours ; in consistency from that of extreme 
tenacity to very watery. In some cases, especially those of the early 



48 



CLINICAL DIAGNOSIS 



apex tuberculosis in which the physical signs are marked and a cough 
present, there is no sputum. For weeks there is usually a slight morn- 
ing sputum, but it may be necessary to urge the patient to expectorate 
this ; in other cases the onset is with a slight hemorrhage ; in other, 
it is at first a pure mucus and hence glairy, containing much myelin, 
giving it the sago appearance. There is nothing distinctive in the 
gross appearance of this sputum. It may last for months, but sooner 
or later there will appear little caseous lumps, one of the first sug- 
gestive signs of tuberculosis. Later the sputum is more profuse and 
mucopurulent, that of chronic bronchitis. As ulceration proceeds it 
becomes more profuse, yellow or greenish in color, and after that of 
any grade or amount, and from mucopurulent to purulent, or even pure 
pus. Microscopically, it contains epithelial cells of all kinds, pus-cells, 
blood, and in some cases, if the sputum be hardened en masse and sec- 
tions cut, giant-cells may be found. 

The variations in the sputum in chronic ulcerative tuberculosis are 
many. " A sudden disappearance of the sputum when before it had 
been abundant, especially in the morning, should always put us on our 
guard. Miliary tuberculosis is occasionally ushered in in this manner" 
(Brown). In cases of sudden heart failure there may be a cessation 
of sputum for one or two days without apparent injury. An abundant 
mucoid more or less frothy sputum marks the onset of miliary tuber- 
culosis in a chronic or a less acute form (Brown). 

One of the most important points in the sputum examination is the 
recognition of the small caseous particles, " rice bodies" (corpora ory- 
zoidea). These should never be searched for at random. The sputum 
should be spread out on a dark plate, or better still, according to Sir 
Andrew Clark's method, squeezed between the surfaces of two plates 
of glass, and then the whole surface scrutinized with a small hand-lens. 
This is the surest way to find these particles, in which one has the best 
chance of finding tubercle bacilli and elastic tissue. Many prefer wide 
Petri's dishes, which are more easily handled and sterilized. These 
small caseous particles are from about 0.5 to 1 mm. in diameter, of a 
white opaque color, more or less rounded in shape, of a bad odor, and 
when picked up with a needle and spread on a slide are found to be 
more brittle and crumbly in character than particles of bread. Casts 
of tonsillar crypts and glands of the trachea, bronchi, and pharynx are 
to be excluded. Several of these are collected on a slide and squeezed 
out under a cover-glass in case elastic tissue is looked for, but if for 
bacilli they are spread by means of another slide, or, what is better, 
spread with a needle the slide held a little distance above a gas flame, 
and stained. 

Elastic Tissue ( see page 29). — The search for this should never 
be at random. It should always be methodical and intelligent, for one 



THE SPUTUM 



49 



can search long and find none, whereas, did he know what particles to 
choose, he might find plenty in the first specimen. Its presence means 
destruction of the lung. As a rule, in tuberculosis the disintegration 
is molecular and the elastic tissue in very fine particles, grayish threads, 
even in single fibres. This tissue may present the arrangement of the 
alveoli, or come from the bronchi or from the blood-vessels. Brown 
spoke of a case in which a little pouch of elastic tissue 8 to 10 mm. in 
diameter, evidently the wall of a cavity, and containing innumerable 
tubercle bacilli, was expectorated. In certain cases it will be found 
early before there is any suspicion of disintegration; in other cases 
death may ensue before any is found, as, for instance, in caseous 
pneumonia. 

Tubercle Bacilli (see Fig. 14). — The search for these, the most 
important proof of tuberculosis, should be made with especial care. 
The caseous particles already mentioned should be selected if present, 
and if none are found, smears are made from the small bloody or 
purulent masses. The bacilli may be present in the bloody masses of 
the initial haemoptysis. One must not give up in case no promising 
particles are found, for bacilli may occur in goodly numbers in the 
watery mucoid sputum as well as in the mucopurulent. It is better to 
exhaust the resources of a careful search by the Sir Andrew Clark 
method for suitable particles before the more elaborate methods are 
employed. Five or six portions of the sputum should be examined. 
Since it is often desirable to demonstrate the few bacilli sometimes pres- 
ent, manv methods have been proposed. These nearly all rest on the 
fact that the sputum- may be rendered homogeneous, then the organisms 
sedimented to the bottom or salted to the top of the fluid. 

To render the sputum homogeneous it may be boiled with an equal 
amount of 5 per cent. KOH ; or it may be diluted with two volumes of 
water and then an equal amount of 5 per cent. KOH added and then 
heated; or what is better, saturated calcium hydroxide, 10 parts, is 
added ; or one adds nine parts of 5 per cent, phenol to one of sputum ; 
or the sputum is digested, 5 to 10 cc. of sputum being mixed with ten 
volumes of 0.2 per cent, soda, 0.5 gm. of pancreatin is then added and 
the mixture left in the thermostat for from six to twenty-four hours. 
A little phenolphthalein is added that one may be sure the reaction 
remains alkaline. Of these methods the first is the least useful, since it 
changes the staining properties of the bacilli. 

The sputum now homogeneous, it remains to concentrate the 
bacilli. This cannot be done by simple centrifugalization, since the 
specific gravity of the bacilli is the same as, or lighter than, that of the 
fluid, hence after standing even eight times as many bacilli may be 
found in the supernatant fluid as in the sediment. The specific gravity 
of the fluid must be made lower than 1010 or higher than 1080 (the 

4 



50 



CLINICAL DIAGNOSIS 



limits of the specific gravity of a culture of these bacilli). The addi- 
tion of an equal amount of alcohol would accomplish the former, but 
since alcohol seems to affect the bacilli it is better to add an equal 
volume of 25 per cent. XaCl solution, allow the specimen to stand for 
a few hours, and then remove the bacilli from the upper layers. The 
specific gravity of sputum varies from 0.929 to 1.2242. It is well 
to add a little egg albumin to fix the organisms to the glass. Some 
prefer to make the specimens on cover-glasses ; more use slides. The 
smears are best made with a needle, holding the slide above a flame at 
such a distance that the specimen is merely warmed. The mucus then 
is easily spread. 

Staining. — The tubercle bacillus is acid-fast, but as there are other 
organisms with this property to the same or a less degree, one must 
be on his guard. The Ziehl-Xeelsen carbol fuchsin is generally used 
(fuchsin, 1 gm. ; absolute alcohol, 10 cc. ; 5 per cent, carbolic acid 
100 cc). The specimen may be stained either by heat or in the cold. 
If by heat, the slide is covered by the stain and then held over a small 
flame of a Bunsen burner until the fluid boils. Fresh stain must be 
constantly added, otherwise the glass will crack or the specimen become 
dry and then it is very hard to decolorize it. The stain should boil well 
for from one to four minutes, or until the crystals of fuchsin are seen 
on the surface. To boil well for a quarter to half a minute is usually 
enough; mere steaming is insufficient. The stain is poured off, the 
smear washed in water, and blotted. By the cold method the specimen 
is immersed completely for twenty-four hours. If cover-glasses are 
used they are floated in a watch-glass full of the boiling stain. It 
should be borne in mind that it is essential to overstain as much as 
possible, since with even the best technique it is quite certain that only a 
fraction of the bacilli will hold the stain. The methods of decolorizing 
van* considerably. One of the best decolorizing agents is 2 per cent. 
HC1 in 80 per cent, alcohol ; the smear is decolorized until only the 
thickest portions are red, then washed in water. Others use 2 5 per cent, 
nitric acid until the fuchsin tint is gone. This may be controlled under 
the microscope. It is then washed in water. If some color returns, 
this specimen is covered again with nitric acid and again washed in 
water. It is then washed with alcohol and then with water. This whole 
process is to be repeated if necessary. When well decolorized, only the 
thickest parts of the smear will show any red. For counter-staining, 
Loeffler's methylene blue may be used (the smear covered with this for 
about five seconds, then well washed). By either of the above methods 
most of all the other " acid-fast " bacilli are decolorized. If, however, 
there is no doubt about the diagnosis, and one wishes merely to follow 
the number of bacilli present, Gabbett's methylene blue is used because 
of its simplicity ( 1 to 2 gm. of methylene blue, i.e., to saturation, in 100 



THE SPUTUM 



51 



cc. of 25 per cent. H 2 S0 4 ). The specimen, dried with filter paper, is 
covered with this for from one to five minutes. It is then washed off 
and examined grossly. If any pink can be seen grossly the process is 
repeated. By means of this stain we both decolorize and counterstain 
*at the same time, hence cannot tell when decolorization is complete. 
The thinner the smear the more quickly is it decolorized. Sulphuric 
acid certainly " burns" the specimen, and the morphology is never as 
nice as with nitric acid, since the bacilli seem thicker and the beading 
is less distinct. In fixing, too high heat should be avoided, since it 
injures their staining quality; in any doubtful cases it is said to be 
better to use the cold method. Pappenheim 19 has recommended a 
stain supposed to be very superior for its differentiating qualities. This 
seems unnecessary, however, to those who have most experience in the 
practical side of the work. 

- - T 
— ' V / 1 




Fig. 14.— Tubercle bacilli, stained with carbol fuchsin, and decolorized with nitric acid. X 900. 

Morphology of the Tubercle Bacillus. — As a rule, they are from 
1.5 to 3.5 microns long and 0.2 micron wide. Sometimes, however, 
they are very much longer, even 1 1 microns. As a rule, they are bent, 
sometimes much curved, and branching forms have been described. 
They may occur in chains. The curving may be so extreme that they 
present a spirochete form. They are often beaded, from one to eight 
beads in a rod, and resemble a streptococcus. This appearance is now 
described as vacuolization, that is degeneration. It occurs in all classes 
of cases. The bacilli are scattered or in clumps, sometimes parallel, 
sometimes crossed. It is doubtful that the young bacilli stain less 
intensely than the older. 

The acid fast organisms have now attracted much attention, and 
their list is rapidly growing. Borrel 20 gives, among others in a long 
list, the Bacillus tuberculosis (Koch); Bacillus leprae; the smegma 
group, from which several have been isolated, and which occurs over 
the whole surface of the body wherever skin secretion collects, in ceru- 
men and other secretions, — also the nose and eye ; the milk and butter 

19 Berl. klin. Wochenschr., 1898, No. 47. 

20 Bull. Inst. Pasteur, May 30, 1904 



52 



CLINICAL DIAGNOSIS 



bacilli (Rabino witch) ; those of certain grasses (timothy hay bacillus 
and the grass bacillus of Moeller); of sewer water; of soil, and a 
bacillus of manure (Moeller). In man such organisms have been 
found in urogenital diseases, typhoid stools, lung troubles (pseudo- 
tuberculosis), and pulmonary gangrene. Similar organisms are found 
in tuberculosis of birds, fish, reptiles, rats, and, of course, of cattle. 
That of bovine tuberculosis is now quite generally granted to be Koch's 
bacillus. Borrel states that many of these cannot be distinguished from 
their appearance alone. 

But in addition to the acid-resisting property, that to alcohol is also 
important, hence our stains now include both decolorizing agents. 
This means that Gabbett's methylene blue is no longer used, with the 
result that the above list is much reduced so far as danger of mistake 
is concerned. 

Some 21 consider that several of these organisms belong in one 
group, including the tubercle bacillus, and are closely allied to the 
actinomycoses. Several organisms from cases resembling tuberculo- 
sis have now been described which resemble much the tubercle bacil- 
lus. Ophiiles, 22 for instance, in five cases of gangrene found acid- 
resisting organisms in each, " long, slender, more or less curved rods 
or threads, with irregularly staining protoplasm, which frequently 
occur in clusters. In all cases it was possible to find individuals which 
showed true branching." But these all decolorized in acid alcohol, and 
were not very resistant to acid. 

The opinion expressed by those who have examined several of the 
above forms is that they decolorize rather easily in acid, and that if 
one use both acid and alcohol there is little danger of mistake from 
those organisms which morphologically resemble the tubercle bacillus. 
Yet it is to be emphasized that these pseudo-tuberculosis organisms are 
studied chiefly from cultures, and hence may not, and in some cases do 
not, have exactly the same staining properties as when in the body 
secretions. It is not so easy to inoculate an animal and recover these 
germs as in the case of the tubercle bacillus. The question in the 
sputum is not so difficult as in the urine, yet it may not be true that 
every acid-alcohol-fast bacillus is the tubercle bacillus, and animal 
inoculation is the ultimate court of appeal. 

In searching for tubercle bacilli, if the sputum be homogeneous it 
is well to study many specimens. Ten are recommended by some. In 
the technique of this clinic, using only selected particles, we consider it 
is necessary to examine but three. If we find none, we prefer to give 
a negative result and ask for another specimen, rather than search 
longer in that same sputum. Bacilli are most numerous in the muco- 

21 See Abbott and Gildersleeve, Centralbl. f. Bakt., 1902, xxxi. p. 547. 

22 Jonrn. of Med. Research, 1902, iii. p. 242. 



THE SPUTUM 



53 



purulent or pure purulent sputum of cavities. They are very rare in 
the fibroid form of the disease, also in the caseous pneumonia before 
disintegration of the lung. One negative examination is valueless. 
Some will search for three days, others say six or seven, while in our 
cases we believe in searching as long as there is sputum, and in one 
case the bacilli were found only on the nineteenth examination, and 
Brown tells of one positive only on the twenty-sixth daily trial. All 
other methods failing, the inoculation into the guinea-pig may be 
resorted to. "It is of doubtful value to put the sputum in the 
thermostat that the bacilli may grow." 

The prognostic value of sputum examination. 23 When it is remem- 
bered that possibly many of the tubercle bacilli are not stained at all ; 
that old foci may give off very few and young foci no bacilli at all, 
however actively they may be forming; that by the occlusion of the 
bronchus the contents of the focus may be shut off entirely for a time 
and when expelled the sputum contain a vast number of tubercle bacilli ; 
that they may be present one day, then not again for months ; that in 
the same specimen the organisms may be abundant in one part of the 
specimen and none in others ; that some persons with fatal tuberculosis, 
have no bacilli in the sputum, as, for instance, caseous pneumonia and 
acute miliary tuberculosis, while in other cases the bacilli are present 
even before the physical signs; lastly, that in the severe cases with 
bronchitis the secretion of the bronchi will dilute the sputum and give 
the appearance of a diminution in the bacilli, it will be seen that one 
must be very guarded in his use of the examination in forming an 
opinion of the prognosis. In general it may be said that while the 
examination of one specimen is of no value for this purpose, repeated 
examinations are of use. Brown recommends the application of a 
modified Gaffky's table in following a case (1/12 oil objective, II 
ocular used). 

I. Only 1 to 4 bacilli in whole preparation. 
II. Only 1 on an average in many fields. 

III. Only 1 on an average in each field. 

IV. 2 to 3 on an average in each field. 
V. 4 to 6 on an average in each field. 

VI. 7 to 12 on an average in each field. 

VII. 13 to 25 on an average in each field. 

VIII. About 50 on an average in each field. 
IX. About 100 on an average in each field. 

Cases are thus classified and designated by the Roman numeral.. 
Among some of the general points it may be said that while rro> 
number, form, arrangement, or staining qualities of the organisms is of 

23 Brown, Montreal Med. Journ., October, 1901 ; Journ. Amer. Med. Assoc., 
February 21, 1903. The reader is referred to these articles, from which the most 
of the following paragraph is quoted. 



54 



CLINICAL DIAGNOSIS 



absolute importance, the continued expectoration of large numbers 
would indicate a cavity ; the sudden increase in their number, diffusely 
spread, very numerous, and an increase in the cellular elements, would 
indicate disintegration; the steady decrease lasting for some time 
would, if the physical signs also improve, indicate improvement; the 
case should be called " healed " only when the bacilli are absent for a 
long time. On the other hand, the continued presence of large num- 
bers of bacilli does not of necessity indicate an active process, as, for 
instance, in Fowler's case, in which for fourteen years bacilli in large 
numbers were constantly present, and yet the case was in fair health 
and even improving. Such a patient, it is needless to say, is the source 
of the greatest danger to his neighbors, expectorating as he may from 
three to four billion bacilli each day. Trudeau has mentioned a similar 
case extending over a period of ten years. 

Many have considered that the form of the bacillus is a more im- 
portant sign than the numbers, the predominance of short rods indi- 
cating a rapid growth, while that of long a slower ; yet both forms 
coexist. Brown considers that while in general morphology gives 
little or no aid, yet a predominance of short rods does indicate a more 
active process. Others claim that the arrangement is the important 
thing, that their presence in clumps and parallel groups indicates a 
lively growth, and groups of short bacilli a bad prognosis. Yet these 
clumps may be found in all cases, though more often in the severer. 
Bacilli which stain deeply are considered to possess an especially bad 
virulence. Yet the exceptions to all such rules are so numerous that 
they may be held only in a very broad way. 

The question is often asked, Is the discovery of a single bacillus 
of importance? Attention should be called to the fact that these 
so-called " single bacilli " are often not bacilli at all. But supposing 
one single bacillus is found concerning which there is little doubt. 
This may have been deposited from the air, and other contaminating 
means are always possible, so the discovery should be confirmed on 
following clays. With careful technique the presence of one bacillus 
is certainly important. On the other hand negative examinations do 
not necessarily exclude tuberculosis. In one case, it was only on the 
nineteenth examination that the bacilli were discovered. 

A fairly accurate estimation of the number of bacilli may be 
made, 24 but for clinical purposes it is not worth the considerable 
trouble it requires. 

Sputum from a Cavity. — Some of the older writers (Winkel) 
have considered that the odor of the breath was of particular im- 
portance. The stagnant sputum from cavities has a heavy penetrating 
sweetish odor, and this gives its odor to the breath. In some cases the 

24 Nuttall, Johns Hopkins Hosp. Bull., May, 1891. 



THE SPUTUM 



55 



sputum from such a cavity in the cup will be odorless, while the breath 
is most offensive (see page 22). 

During cavity excavation the sputum is mucopurulent, expelled in 
masses which flatten in the cup to form coin-shaped clumps, the so- 
called " nummular" These are seen especially in the dark green or 
grass-green sputa of caseous pneumonia with cavity formation. They 
are green or dirty grayish-green in color, isolated, do not coalesce, and 
consist chiefly of pus; they sink at once in water; their odor is not 
bad. Some are full of small points, even millet-seed in size, containing 
much black pigment and elastic tissue, granular detritus, and few pus- 
cells. The cavity is full of such material. These are not, as was 
formerly supposed, characteristic of cavity, for masses macroscopically 
similar arise also in the larger bronchi. When softening is rapid 
the expectoration of 100 to 150 cc. a day of sputum is not rare. From 
large cavities most is expectorated in the morning. Blood is often 
present, which, if retained in the cavity, is expectorated in blackish 
clots. In case the cavity communicates with the bronchus by a fine 
hole, there may result the same skein of pus described under abscess 
of the lung. The sputum often has a sickening sweetish odor. In 
case bronchiectasis, gangrene, or putrid bronchitis occurs, with de- 
composition the odor may be foul, but it is remarkable how seldom 
these occur. 

As the cavity clears and becomes lined with connective tissue, the 
character of the sputum changes considerably. We then have the 
" sputa globulosa," consisting of balls of a grayish-white color, thick, 
rounded, shaggy masses,— a conglomerate of mucus, detritus, and 
pus, — some of which sink in water, but not all. Large tissue frag- 
ments are rare unless the connective-tissue proliferation be rapid and 
dissects off particles of the necrotic cavity wall. 

Hemorrhage. — This occurs in the majority of cases, in amounts 
varying from small flecks to cupfuls. In some cases the number of 
hemorrhages is so great they are termed " hsemoptysical" cases. 
Hemorrhage occurring early in the disease is very frequent, but sel- 
dom great, and recurs often. This is the so-called " inflammatory 
hemorrhage," seen especially at the onset of a caseous pneumonia or 
during acute exacerbations of the consolidation. It has the same sig- 
nificance as in acute lobar pneumonia, the blood escaping by diapedesis 
or from erosions of the mucosa. Later in the disease, however, the 
hemorrhages are of a very different character, since then profuse and 
sometimes fatal, occurring without warning in a person apparently 
recovering. Such arise from the rupture of the small miliary aneu- 
risms in arteries which cross a cavity or are exposed in its wall. 

Croupous Pneumonia. — In true lobar pneumonia very rarely there 
is no sputum at all, except in the case of very old or very young 



5G 



CLINICAL DIAGNOSIS 



patients. At the onset a hemorrhage is sometimes the initial symptom. 
In other cases the sputum is mucoid and abundant for even four or five 
days, but very soon becomes bloody, at first from the presence of un- 
changed red blood-cells. This sequence, mucoid then blood sputum, 
marks the progress of the inflammation from bronchi to alveoli. The 
sputum at this stage is remarkably transparent, since the cells are not 
present in rouleaux but are scattered singly throughout the mass. 
Soon, however, the sputum becomes rusty, is then characteristic in 
appearance, and when typical a diagnosis may be made from it alone, 
even when other signs fail. This rusty sputum is homogeneous, glairy, 
almost transparent, so tenacious and jelly-like that the cup can often be 
inverted without the loss of any. The color is due to the transformed 
haemoglobin, and microscopically very few red blood-cells can be 
found. The above-described sputum is present only in cases in which 
there is not much catarrh of the larger bronchi, which furnishes muco- 
purulent masses. In amount it varies from about 150 to 300 cc. per 
day. When small in amount it dries rapidly in the cup, since there is 
so much albumin, so little mucus. 

Blood is a quite constant feature of pneumonic sputum. For the 
most part uniformly distributed, it often is also present in streaks 
of varying size, while in other cases the sputum is almost pure blood. 
If the process extends to another part of the lung a rusty sputum 
may again become bloody. 

In color it is typically of a rusty yellowish-brown hue, but in other 
cases with physical characteristics the same it is of an orange-yellow, 
a lemon-yellow, or a grass-green color; in fact, all.the possible shades 
which are seen in subcutaneous bruises. These colors are due to dif- 
ferent oxidation stages of unknown haemoglobin derivatives (Traube). 
The sputum may appear jaundiced, but this term should never be used 
unless the skin is icteroid. 

Microscopically is seen a transparent background with some red 
blood-cells which are swollen and pale as a rule, others well preserved ; 
many epithelial cells, columnar or pavement; lymphocytes, granular 
cells, and oil globules. Chemically, this sputum is characterized by 
the absence of the alkaline phosphates, the excess of potassium over 
sodium, an increased amount of sulphates, and a large amount of 
soluble proteid. The fixed salts, usually about 18 per cent., are in these 
cases about 26 per cent. 

At the crisis the sputum loses its rusty color and becomes muco- 
purulent, more or less abundant, and finally white mucus. " In no 
other (disease) is the cycle of sputa changes so marked or of so great 
diagnostic value as in this disease" (Mackenzie). 

In addition to the study of the individual cases, a series of ninety-four were 
compiled to get some general idea of the relative frequency of the different forms 



THE SPUTUM 



57 



of sputum in our cases. Twenty-one per cent, of the cases denied having had any 
sputum at the onset of the disease; 46 per cent, denied that it was bloody, 
whereas 33 per cent, stated that the first sputum noticed was slightly bloody. 
During the course of the disease 16 per cent, of the cases had little or almost 
no sputum. One case was in the hospital seventeen days without any expectora- 
tion, and other cases about seven days. In 32 per cent, the sputum was typically 
rusty ; in 39 per cent., not only rusty but blood-streaked ; in 3 per cent., very 
bloody : while in 10 per cent, at no time during the disease was any blood noted. 

Variations. — If bronchial catarrh be also present, that is, when 
a pneumonia supervenes on a chronic bronchitis (Traube), the sputum 
consists of mixed rusty pneumonic and mucopurulent bronchitic sputa. 
It is therefore quite fluid. It may not be rusty at all; it may be 
bloody mucoid pus. In some cases, instead of being rusty it is very 
bloody ; e.g., in the so-called " hemorrhagic pneumonia " of the aged. 
In chronic passive congestion due to heart, lung, or renal disease, we 
have the characteristic " brick-red " sputum, thin like that of oedema, 
and very bloody. This is the sputum of " congestion " or " serous 
pneumonia" (Traube). It is seen when the inflammation proceeds 
by starts. 

The green sputa are of particular importance : in cases of delayed 
crisis and lysis but in which perfect resolution may follow; in a case 
clinically becoming serious it is an important warning; it may be the 
first symptom of abscess of the lung, and should always arouse sus- 
picion in a case with an abnormal course ; in cases in which the skin 
is jaundiced it has no significance; and lastly and most important, it 
may be the first indication that the diagnosis of croupous pneumonia 
was incorrect, and a search should at once be begun for tubercle 
bacilli. 

The sputum in the case of pneumonia which ends in necrosis or 
gangrene presents characteristic changes. It soon loses its tenacious 
and rusty character, becomes more fluid, its color changes from 
" rusty " to " coffee," then to " prune-juice," and later to " chocolate." 
The red blood-cells disappear. The odor, at first absent, is stale and 
later decidedly fetid. Granular detritus appears, and then necrotic 
fragments. Or it may throughout be prune- juice in nature, but this is 
rare. From these sputum changes the diagnosis can be made before 
the tissue fragments appear. The reason for the colors is not clear 
since the red blood-cells are described in some cases as well preserved. 

The prune-juice sputum is also of particular importance. It usu- 
ally indicates a severe type of the disease ; in some cases, particularly in 
old persons, oedema of the lungs develops during a pneumonia, — and 
the rusty sputum becomes " prune-juice " in color; in other cases 
it indicates a low type of the disease; while still again, and in these 
cases without any serious significance, it merely signifies a beginning 
resolution. 



58 



CLIXICAL DIAGNOSIS 



Fibrin coagula are commonly found in a rusty sputum, as often, 
says Dr. Osier, as the search is made for them. Suspicious masses 
should be shaken out in water. These may be beautiful branching 
fibrin casts of varying size, the larger with hollow branches. In some 
very pretty casts there are found clots and small collections of blood 
in the lumen at each bifurcation of the branches. In one case the cast 




Fig. 15. — Fibrin cast from a case of double pneumonia. Natural size. The patient was a man 65 
years of age. The cast was expectorated on the sixth day of a double pneumonia, followed by hemor- 
rhage. Death on the seventh day. 

seemed to be from two entire lobes, one of each lung, and hence to 
cross the bifurcation of the trachea. This cast is pictured in natural 
size as Fig. 15. Curschmann spirals, and, in fact, every constituent 
of asthma, may be found. 

This was beautifully illustrated in Vierordt's case 23 of typical pneumonia but 
with intense general bronchitis and bloody sputum on the fourth and fifth days, 
with many fibrin coagula, which were particularly beautiful on the seventh day, at 

25 Berl. klin. Wocherischr., July 16, 1883. 



THE SPUTUM 



59 



which time also spirals were found and resolution began. From this time on were 
found beautiful Curschmann spirals, but no Charcot-Leyden crystals. 

In the sputum of cases of acute lobar pneumonia will usually be 
found Diplococcus pneumoniae in large numbers. This is of great 
aid in the diagnosis of doubtful cases of lung trouble. Since this 
organism does grow in the mouths of about 50 per cent, of normal 
persons, although its presence there is determined by animal inocu- 
lations and by cultures but seldom if ever by smear preparations made 
from the sputum, and since it is often found in small numbers in 
smears of the sputum in various diseases, its demonstration is impor- 
tant only when it is present in large numbers. A thin film prepara- 
tion of the sputum is made on a glass slide, dried in the air and then 
run slowly three times through a flame to fix the specimen. This 
is then stained with bacterial stain, such as an aqueous solution of 
methylene blue ; but since the Gram staining quality of this organism 
is important, it is well to use this method (see page 85). 

There is such a confusion of ideas as to the real value of the study 
of stained smears of sputum that a few words at this point may be 
appropriate. The student should be encouraged to make smears of 
the fresh sputum from the greatest variety of cases. He will find 
many of them full of organisms and will see that the number of these 
organisms increases rapidly as the sputum stands in a warm room. 
The cells full of biscuit-shaped diplococci especially will attract atten- 
tion. The pneumocoecus and bacteria resembling Bacillus influenzae 
will be found so often that one often doubts that there is any value at 
all in this examination. But if the sputum be expectorated into a 
sterile cup, the smears made immediately, and the question of abund- 
ance and not the presence of certain forms considered, this examination 
will be found of a little, although of very little, value. 

Diplococcus pneumoniae is a small, oval coccus, about one micron 
in longest diameter, usually arranged in pairs, their short diameters 
parallel, but also often in chains. Even when in chains, one can 
usually see that the individuals are oval, their long diameters all in 
the line of the chain. The free ends of the diplococci are often pointed 
like a lancet (or better still, a candle flame), hence the name, " Diplo- 
coccus lanceolatus." Diplococcus pneumoniae is a capsulated organism 
whether in pairs or chains. There is always doubt about the identity 
of any non-capsulated diplococcus. 

Among the capsule stains are the following. In all these stains 
the important point is to avoid the use of pure water. 

Welch's Method. — The film, made in the manner described on 
page 50, air-dried and then passed through a flame slowly three 
times, is first covered with glacial acetic acid for five seconds. The 



60 



CLINICAL DIAGNOSIS 



excess of the glacial acetic acid is then removed with filter paper 
and then washed off with aniline gentian violet (see page 85) until 
all the acetic acid is removed. 

The film is then washed in an 0.85 to 2 per cent, aqueous solution 
of sodium chloride until the stain is washed off. The specimen is 
examined at once in this fluid. Sometimes it may be dried and 
mounted in balsam, but these preparations are often unsatisfactory. 
The capsule forms a pale violet halo around the deeply stained 
diplococci. 

Hiss's Potassium Carbonate Method* — The film preparation 
of sputum is dried in the air and passed through the flame in the usual 
manner. It is stained for a few seconds in a half -saturated aqueous 
solution of gentian violet. The dye is then washed off with a 0.25 
per cent, aqueous solution of potassium carbonate, and the prepara- 
tion studied in this fluid. The capsules are large, prominent, and are 
either stained throughout or more densely at the periphery. 

Very fair capsule stains may also be obtained by simply stain- 
ing for about 30 seconds with the ordinary aqueous gentian violet 
solution (5 cc. sat. ale. sol. to 95 cc. distilled water), then washing 
with a 1 per cent, potassium carbonate solution and studying the 
specimen in this fluid. The following method is satisfactory when 
permanent specimens are desired. 

Hiss's Copper Sulphate Method. — The dried film is covered with 
a 5 per cent, or 10 per cent, aqueous solution of gentian violet or 
fuchsin (5 cc. sat. ale. sol. to 95 cc. distilled water), and held over 
a flame and allowed to steam for a few seconds. The staining fluid 
is then washed oft with a 20 per cent, aqueous solution of copper 
sulphate. This solution is then poured off, and the specimen thor- 
oughly dried between filter papers. When dry it is mounted in balsam. 

Buerger's Method.^ — Before the spread is completely dry it is 
covered with Zenker's fluid minus acetic acid and gently warmed for 
3 to 5 seconds over a small flame. It is washed rapidly in water and 
flushed once or twice with 80 to 95 per cent, alcohol, and then covered 
with tincture of iodine which is allowed to remain on the cover glass 
for 30 to 60 seconds or even longer. The iodine is washed off with 
alcohol and the specimen dried in the air. The staining is done with 
fresh aniline oil gentian violet in from 3 to 5 seconds, the excess of 
stain being removed with 2 per cent, salt solution. The preparation is 
examined in this fluid. 

* Studies from the Dept. of Pathology of the College of Physicians and 
Surgeons, Columbia Univ.. New York. 1904-1905. vol. x. 

f Report of the Medical Commission for the Investigation of Acute Respira- 
tory Diseases of the Dept. of Health of the City of New York ; Part I., Studies on 
the Pneumococcus, 1905. 



THE SPUTUM 



6] 



For methods of cultivation of Diplococcus pneumoniae the reader 
is referred to Buerger's article (The Journal of Experimental Medi- 
cine, 1905, vol. vii., No. 5). The student should always remember 
that by far the quickest and surest method of identifying this organ- 
ism, is to inject a little of the culture medium, sputum, pleural fluid, 
or whatever specimen contains the organism in question into a mouse 
or rabbit. The animal will die in from 24 to 48 hours of septicaemia 
and in smears of the beast's blood can be found in goodly numbers 
these capsulated diplococci. 

In the subacute indurative pneumonia the sputum may contain 
blood, but is seldom rusty. It is usually abundant, and there is a 
decided tendency for it later to become fetid. 

Chronic Interstitial Pneumonia. — In this disease the cough is 
often paroxysmal, and in general the expectoration is copious, of a 
mucopurulent or a seropurulent nature, and sometimes fetid. Hemor- 
rhage is present in about one-half of the cases. 

Bronchopneumonia — This term, which includes also the hypo- 
static, and the pneumonia of aspiration, is accompanied by an expec- 
toration which combines the bronchitic with the pneumonic, that is, 
a mixture of rusty with mucopurulent sputum. Sometimes the transi- 
tion from a bronchitis to a bronchopneumonia may be suspected from 
the changes in the sputum; it becomes less in amount, viscid, difficult 
to expel, and may be streaked with blood, but it is almost never 
typically rusty.- 

Influenza. — The sputum in the pulmonary type of this disease as 
it occurs in epidemics is at first tenacious and scanty, but later in- 
creases, becoming often large in amount, a mucopurulent, very thin 
fluid, in which purulent masses swim. It is often quite bloody. Pfeiffer 
considers that the most characteristic sputum is greenish-yellow in 
color with lumps of pus in coin-shaped masses. In this sputum the 
influenza bacillus may early be isolated in almost pure culture. 

Pulmonary infection by the influenza organism is not confined 
to times of epidemics, but has proven a very common disease. Lord 26 
found this bacillus in 60 of 100 non-tuberculous cases with cough, and 
in 29 of these in practically pure culture. Such cases are mistaken 
for chronic bronchitis, asthma, or even tuberculosis, there being 
nothing distinctive in the clinical picture; the organism must be 
found. The duration in such cases may be months or years, and in 
one of Lord's cases it lasted forty-four years. Since making a routine 
examination for this organism in this clinic a surprisingly large number 
of cases has been found. For Lord's method of cultivating the 
organism the reader is referred to his paper. 

20 Boston Med. and Surg. Jour., December 11, 1902. 



62 



CLIXICAL DIAGNOSIS 



To recognize these bacilli in the sputum it is not so much a matter 
of stain as familiarity with their morphology. They are first decolor- 
ized with Gram's, and a good counter-stain then used. Bismarck brown 
or safranin is the best counter-stain. ( Twenty cc. of saturated alco- 
holic solution of Bismarck brown diluted with 80 cc. of water.) 
Methylene blue often gives an uncertain color. 

Smith's stain is preferred by some, and in the hands of one accus- 
tomed to it, it gives beautiful pictures, 27 but others find it too compli- 
cated and unsatisfactory. Very fresh sputum is examined ; small 
tenacious purulent particles are to be selected for examination ; and 
very thin smears are made. 

A very thin cover-glass smear of sputum is fixed by heat (passing it two or 
three times through the flame), and covered with aniline oil gentian violet. It is 
held well above the flame, allowed to steam, but avoiding burning. The excess 
of stain is washed off with a solution of iodine in potassium' iodide (iodine, 1 part: 
KI, 2 parts; water, 300 parts). The specimen is then covered with this IKI 
solution and the steaming continued. It is then decolorized as much as possible 
I — 1 " r~ I 

*** / (Mb 

• $ 

- - " : ',17 ■«*4m-*'^ 

[ «« IOC/Y**0O£ j 

FIG. 16. — Sputum of influenza stained with Gram's and Bismarck brown, showing the Bacillus influenzae 
(brown), Diplococcus lanceolatus, et al. (blue). X 900. 

with 95 per cent, alcohol, and washed a few seconds in an alcohol-ether mixture 
(95 per cent, alcohol, 4 parts; ether, 6 parts). Wash in water. It is then stained 
a few seconds in a saturated aqueous eosin solution, the excess of eosin washed 
off with Loffler's blue, then the specimen covered with this blue, steaming as before. 
Decolorize slightly with 95 per cent, alcohol ; wash in absolute alcohol, then xylol, 
and mount in Canada balsam. 

The method used here is as follows: the fixed smear is stained 
with the above-mentioned aniline oil gentian violet (Sterling's) for 
one and one-half minutes, and washed in water ; covered with Gram's 
solution one and one-half minutes, and again washed in water ; 95 per 
cent, alcohol, 5 minutes; wash in water; 0.2 per cent, aqueous Bis- 
marck brown, one minute; wash, dry, mount. 

The organism (see Fig. 16) is one of the smallest of the bacilli, 
a short rod with rounded ends, often with polar staining, which 
takes at best a rather faint stain. They occur in groups sometimes 

^Boston Med. and Surg. Jour., December 11, 1902. 



THE SPUTUM 



63 



of large size and free, and in groups inside leucocytes. The question 
has been asked if this intracellular occurrence does not indicate a 
process near its close. 

Whooping-Cough. — During the catarrhal stage the cough is, as a 
rule, that of a dry bronchitis. A little later the sputum of bronchitis 
presents no especial features, but during the paroxysmal stage the 
sputum is expectorated by very severe paroxysms of coughing in 
amounts very small each time, and yet in the aggregate considerable. 
Such sputum contains almost pure cultures of bacilli. 

Glanders of the Lung. — In case the disease extends from the nose 
to the bronchi and there excites inflammation, the severe cough is 
said to be accompanied by a profuse purulent expectoration. 

Asthma. — In acute bronchial asthma the sputum is perfectly char- 
acteristic, beginning, as a rule, only as the paroxysm begins to pass 
off, or, as the patient describes it, " breaks," and bringing with it much 
relief. During the paroxysm itself there is often no sputum ; in other 
cases it is scanty, clear, consisting of thick glairy mucous balls, the so- 
called " perles of Laennec," which swim in a thin clear frothy mucus. 
In other cases it is less characteristic, of a greenish-yellow tenacious 
mucus, and described by the patient as " rubber-like." These perles are 
pellets of a semi-transparent mucus, of a pale gray color like boiled 
tapioca. In them are mucous moulds of the smaller tubes, and some 
on unravelling are Curschmann's spirals. Early the sputum contains 
a few eosinophilic cells and many alveolar epithelial cells with myelin 
degeneration. The moulds are small cylindrical or sausage-shaped 
masses consisting of thick threads, or plugs, which may be from i to 
1.5 cm. long. Some branch, some are narrow or straight, while others 
are spiral. These have the same significance as the Curschmann 
spirals. The amount of sputum at this stage may be from very little 
to 50 cc. In the sputum also may be found alveolar cells with myelin 
degeneration and very few leucocytes. 

In 27 per cent, of our cases there were in some of the paroxysms slight hemor- 
rhages. As the attack " breaks," however, the sputum becomes thinner, more 
liquid, frothy, and much more abundant, even 200 cc. in twenty-four hours. It 
is then a clear viscid fluid, which has lost considerable of its tenacity, in which 
float mucopurulent masses. In others of our cases, however, it was still scanty, 
tenacious, viscid, yellowish-white, and decreased in amount until it disappeared 
entirely. The leucocytes are present in large numbers, and a large percentage of 
them may be eosinophile cells. There are also present large numbers of alveolar 
epithelial cells, many of them with marked myelin degeneration ; few red blood- 
cells. In one of our cases was present a true bronchial cast about one and three- 
quarters inches long, consisting of mucus and eosinophile cells. Curschmann's 
spirals were also present. 

During the next two or three days the character of the sputum changes much. 
It is often small in amount and mucopurulent, with, however, some clear frothy 
fluid. As a rule, now no Curschmann's spirals are found, although in one case, 
in which they had been present in good numbers, they were more beautiful than 



64 



CLINICAL DIAGNOSIS 



before. Fibrin casts of the bronchi are sometimes present, occurring with the 
spirals, which they may exceed in numbers. At the tip of some of the branches 
the cast may be continuous with the central fibre of a typical Curschmann spiral. 
Along with the spirals occur large numbers of eosinophile leucocytes. In some 
cases, but rarely, Mastzellen. Where the eosinophile cells are increased it is 
common also to find the Charcot-Leyden crystals. Calcium oxalate crystals have 
also been found. As a rule, the sputum ceases as soon as the attack is well over. 
In some cases, however, it is almost continuous, even 100 cc. per day, but may 
have sputum-free intervals. 

Curschmann's Spirals. — These beautiful structures occur at 
some time in perhaps every case of true bronchial asthma. This, how- 
ever, does not mean that they will be found in every paroxysm of this 
disease in which they are sought. We have in mind one case, a man 
whose sputum several years ago furnished the students with the most 
beautiful spirals. He has since then been admitted during the past 
fifteen years fourteen times in acute attacks of asthma. Only on one 
day of this period was a spiral found. While they may be present 





(X. r- Cgift 






' 


H B, 



Fig. 17.— Curschmann's spiral, from the sputum of a case of asthma. X 200. 

during the paroxysm, they are found particularly just at the end, as 
the sputum increases, and, as a rule, are absent after it has become 
mucopurulent. They may be present in large numbers. 

In general, two forms may be described. The first is a spirally 
twisted strand of mucus enclosing leucocytes, eosinophiles, and Char- 
cot-Leyden crystals. The second and more beautiful form consists 
of a tight skein of mucus wound around a central fibre. This 
may be from i to 2 cm. or more long and 1 mm. broad. It may be 
branched. These spirals have two parts; the " mantle," which is the 
mucus surrounding the kk central fibre." The mantle contains, besides 
eosinophiles, many pigmented epithelial cells, some ciliated cells, and 
Charcot-Leyden crystals. The arrangement of these cells, not mixed, 
but in lines and groups, is interesting. The central fibre, which prob- 
ably consists of transformed mucus, is very refractive. It is a spirally 
twisted strand, homogeneous, with a sharp contour or saw-edged. 
While the caliber varies, it is quite constant throughout one spiral. 
Central fibres are subdivided into the small size, from 0.5 to 1 micron 
in diameter, the medium-sized, 3 microns, and the thickest, even 18 



THE SPUTUM 



65 



microns in diameter. In sputum which was hardened en masse and cut 
in sections they were found by Ruge to be solid without evidence of 
the lumen which others have claimed. These fibres are sometimes well 
developed, sometimes present only as a trace; they may be absent. 
They end sometimes as a thread, while in other spirals they give off a 
multitude of lateral threads. The finer are often branches of larger 
threads, or the smaller may unite to form a larger. Some of the larger 
types give off fine threads radially to the mantle in all directions. In 
structure some are lamellated, while others seem to be a bundle of 
parallel threads, spirally twisted. These central fibres may be dif- 
ferentiated by staining, and hence are not optical phenomena presented 
by the most compressed part of the spiral, as some claim. They occur 
alone sometimes (see Fig. 18), and have the same significance as per- 



Fig. 18.— Free central fibre of a Curschmann's spiral, from the sputum of a case of asthma. X 200. 



feet spirals. When alone they are spirally twisted. In some cases 
occur perfect spirals ; in others, many free central fibres ; again others, 
free central fibres, and some with very imperfect mantles (see Fig. 



As regards the origin of the spirals, the central fibres are certainly not casts 
of the smaller bronchi, since they are often only about one-tenth as big. Schmidt 
claimed that for their formation the epithelium must be well preserved, that they 
consisted of mucus secreted in the smaller bronchi, the centre representing the 
most twisted part, that is, of the greatest relative compactness ; and for their 
formation a tough mucus was the important thing. Hoffmann claimed that the 
smaller bronchi are themselves spirals, which become straightened out as the lung 
expands, and that the tough mucus forced through these spirals can assume a 
spiral shape. Others claim that the cilia motion in the bronchi must be in spiral 
waves ; others that the spiral is formed from a straight band of mucus which in 
passing the bifurcation of two bronchi is whipped into a spiral by the cilia of the 
other bronchus, the direction of whose cilia motion will be tangential to the axis 
of this thread. Gerlach gave three conditions necessary for their production, — a 
small amount of very viscid sputum, very forcible respiratory movements, and 
clear bronchi. These three conditions are best given in asthma. He claimed that 
the mantle and central fibre are formed in the same place, but that the latter is 
formed later and is merely an optical expression for that part of the mucous mass 
which has been twisted the most. We would say, however, from studying the 
spirals we have seen, that while the central fibre is itself spirally twisted, there 
are many fewer revolutions per unit of length than in the mantle. 

In cases which we recently had a chance to study the spirals were beautiful, 
about 2.5 cm. long and 1 mm. broad, and with a central thread so refractive that it 
could be definitely seen by the naked eye. While fresh it is interesting that this 
thread could not be studied with the higher powers because of its high refractivity, 




17)- 



5 



66 



CLINICAL DIAGNOSIS 



and seemed to be merely an optical phenomenon. At certain points, however, where 
the mantle was thin and particularly after the spirals were allowed to dry some- 
what, it could be easily studied, and was found in some cases to be a bundle of 
twisted fibres. The mantle was very tightly twisted, and on cross-section at 
certain points it could be seen that it consisted of spirally wound sheets of mucus 
reaching from the central thread to the periphery. It was filled with various cells ; 
among these, squamous epithelial cells, very many alveolar cells, many containing 
coal pigment, and others modified haemoglobin. In all fields were a great number 
of eosinophiles, in many, cylindrical cells which appeared ciliated, although the 
cilia were not as distinct as might be desired, and among them goblet-cells. It is 
interesting that in the structure of the spiral these cells were not mingled, but 
each variety occurred in groups or lines and large numbers in each group. The 
Charcot-Leyden crystals occur singly or in clumps, some quite large. One was 
projecting from an eosinophile cell and surrounded by its detritus. In some fields 
full of leucocytes search was made in vain for one which was not an eosinophile. 
In one specimen was found a strip of mucosa of cylindrical epithelium. Other 
spirals had no core, and some spirals consisted merely of a very large refractile 
central fibre. One spiral was particularly interesting ; two separate strands of cell- 
rich mucus, discrete at first, became twisted, the one within the other, into a spiral, 
and yet each could be traced separately for a time until the coil was so tight they 
could not be distinguished. The inner was thick, the outer thin, and at the end 
where they were not spirally twisted their structure could be seen, a band of mucus 
with detritus and cells in lines ; almost all the leucocytes were eosinophilic. If the 
spirals be allowed to dry, the central thread is much more distinct. In some cases 
they are a bundle of longitudinal fibres slightly twisted. This case was a typical 
one, with spirals, immense numbers of eosinophile cells, and a large number of 
epithelial cells, the alveolar with the various forms of pigment, and the cylindrical, 
both ciliated and goblet. 

In another case were many central fibres without mantles, and some with a 
few fibres wound around them. These fibres, forming these imperfect, loose 
mantles, were remarkably thread-like and of quite uniform diameter. 

Charcot-Leyden Crystals. — These Charcot-Leyden crystals 
(see page 34), present wherever the eosinophile cells are increased, 
are very common in asthmatic sputum. Their number may greatly 
increase as the sputum stands. These crystals occur in groups, form- 
ing specks of a greenish-yellow color, which masses may be even seen 
with the naked eye. They may give to the spiral a yellowish-green 
color macroscopically when present in large clumps along the spiral. 
It is important to bear in mind that their size varies so that their 
presence can be excluded only when a search has been made with the 
oil-immersion lens. They increase in size and number as the attack 
lasts. In cases in which none were found at first they will appear in the 
sputum if it be kept in a warm chamber. Concerning their composi- 
tion all that can be said is that there exists in the sputum a substance 
which after expectoration is crystallizable in this form. The same is 
true of ty rosin, and the French seem eager to identify the two. They 
practically always occur in asthma, but careful search is necessary, and 
in case they are not found it is well to let the sputum stand. 

The alveolar epithelial cells laden with golden-yellow pig- 
ment may occur in large numbers and fill a considerable part of the 
mantle of some of the spirals. They occur chiefly in clumps packed 



THE SPUTIWI 



67 



together, and in other parts of the specimen none will be found. It is 
interesting to see what large masses of these cells will occur in certain 
parts of the spirals. Their origin, v. Noorden says, is clear; that in 
asthma we have frequently small traces of blood in the sputum, and 
that this is the source of the pigment of these phagocytes. These cells 
are similar to the Herzfehlerzellen seen in chronic passive congestion. 

There is a well-marked group of cases which may present a 
transitional stage between asthma and fibrinous bronchitis. The 
sputum contains spirals, Charcot-Leyden crystals, eosinophile cells, all 
the constituents found in asthma, but also casts of the smaller bronchi, 
which, however, do not branch much and which may at one end tail 
off into the central fibre of a true spiral. In one case of Dr. Osier's, 28 
already mentioned, these casts were i to 3 cm. long. 

Acute Bronchitis. — The sputum in acute bronchitis is at the onset 
very scanty, or even absent. When present this " sputum crudum " is 
usually tenacious, viscid, very hard to expectorate, and of a frothy 
transparent appearance. It consists of almost pure mucin. Micro- 
scopically a few leucocytes and red blood-cells can be found, also a 
few bronchial epithelial cells, some ciliated and some with the cilia 
in motion. There are also a few mononuclear leucocytes, the so-called 
" mucous corpuscles " which are derived from the lymphatic masses 
along the tract. In certain conditions so many of these epithelial cells 
are present that the term " desquamatory bronchial catarrh " was ap- 
plied. Myelin drops are present, but they are not very numerous and 
in only the simpler forms. Such sputum is the result of an increased 
secretion of the mucous glands, together with the desquamation of a 
few epithelial cells. As a rule, this clear sputum is present for about 
two days, yet during the whole course of the acute bronchitis the 
sputum may represent only a hypersecretion, and hence present the 
above character. In some of our cases it was two weeks before very 
much pus was present. In some cases the sputum at this stage is less 
viscid, hence Biermer's adjective, " seromucous." 

After the first two days or more the cough usually " loosens." The 
sputum is increased in amount, less viscid and less tenacious, and may 
be like the white of an egg in appearance, since it is frothy and shows 
whitish streaks. Sometimes it is blood-streaked, while in other cases 
there is considerable blood at the beginning of the attack ; the latter 
was true in 33 per cent, of our cases. 

The sputum now becomes mucopurulent. It contains all of the 
above elements, but the pus-cells are very much increased. These may 
be uniformly distributed, and give the sputum a uniform yellow color, 
or they may be present in purulent islands. There are still many epithe- 
lial cells present, but these have lost their shape and their cilia, are now 
28 See Bettmann, Amer. Jour. Med. Sci., February, 1902. 



68 



CLINICAL DIAGNOSIS 



round, and often fatty. Such sputum was formerly called " sputum 
coctum." In a typical case the sputum then becomes almost purulent, 
the pus being poured from the inflamed and probably partially denuded 
mucosa. This sputum is opaque yellow or a yellowish-green, and is 
often expectorated in masses. The amount is, as a rule, from 100 to 
200 cc. in twenty-four hours. Most is expectorated in the morning. 
Microscopically, it is found to contain much mucus and much myelin. 
There are no cylindrical cells now. There are usually some red blood- 
corpuscles, but the leucocytes predominate in the field, and are chiefly 
polymorphonuclears, although a certain number of mononuclears are 
found. Alveolar epithelial cells, some containing pigment and some 
fat granules, may be found if searched for. Fat is also present in 
larger masses, which in shape resemble a cell, although now neither 
nucleus nor protoplasm can be demonstrated. The sputum of some 
cases is characterized by the abundance of fat, present in cells, in 
droplets, and in the above-mentioned masses of droplets, while in other 
cases but little is found. The reason for this difference is not known 
(Hoffmann). Bierman divided the purulent sputa into three classes. 
His division has been severely criticised, although the nummular 
variety was present in a few of our cases. With improvement the 
sputum becomes more abundant, more purulent, and less tenacious. 
It then, as improvement continues, diminishes in amount and finally 
disappears. The above is a quite typical sequence. The following 
varieties, however, occur. In 13 per cent, of our cases in which the 
diagnosis of acute bronchitis was made because of the physical signs 
on auscultation, no sputum was at any time to be obtained. In some 
cases so tenacious was it that it could not be expectorated, the patient 
often vomiting in the attempt. In other cases the sputum is muco- 
purulent and fairly abundant from the very onset. It is interesting, 
however, that in a large number of these last cases it is probable there 
was a slight chronic bronchitis already present, since over 50 per cent, 
of these patients stated in their history that they were subject to coughs 
and colds. This was true in less than 20 per cent, of those in which 
the sputum at the onset was of small amount. In general it seems true 
that a large amount of sputum means a chronic trouble. In about 
35 per cent, of our cases the sputum was viscid and very tenacious and 
scanty throughout the whole course, the patient suffering from a dry 
cough for a few days after the disappearance of the sputum. Many 
cases have at the end of the attack a common sputum, not mucopuru- 
lent, but consisting of a watery serum in which swim islands of pus 
which are globules about 1 cm. in diameter, consisting of mucus loaded 
with pus-cells. Such a sputum on standing will separate into two 
layers, the upper watery and transparent, the lower purulent. This 
was true in 10 per cent, of our cases. Other cases were interesting in 



THE SPUTUM 



(i!) 



that the sputum at the end of the attack became again as at the be- 
ginning of a pure mucous type. In acute bronchitis much valuable 
information may be obtained from the sputum, since it is the best 
index of that which occurs within the chest. 

In the so-called capillary bronchitis, that is, acute bronchitis of the 
smaller tubes, the cough is frequent, often paroxysmal, and at first dry. 
It may remain so, the sputum being absent throughout the entire 
course, or expectorated in small quantities with great difficulty. In 
these cases a diminution in viscosity is a sign of improvement. 

Chemical Analysis. — The chemistry of the sputum in this dis- 
ease has a very slight interest. Of the cases which have been reported 
by Bamberger, Biermer, and Renk, the water has varied from 95.62 
to 98.3 per cent.; the organic substances, from 1.17 to 3.7 per cent.,, 
while the inorganic, from 0.457 to 0 -7& P er cent. 

Chronic Bronchitis. — Under this heading may be included all cases 
from the simple subacute, in which case a cough has merely " held on" 
for several months, to those cases which give a history of slight cough 
with expectoration extending over twenty-five or more years. Among 
the cases which may be considered subacute we have those in which 
for several weeks or months the sputum is tenacious, viscid, and very 
small in amount. The patients describe this as consisting of thick 
leathery lumps ; in other cases, as a white sticky mucus. Later on it is 
apt to become more and more abundant and mucopurulent, and hence 
yellower. Some sputa have a dark greenish color and a foul odor 
which will last for weeks. Such sputum as exemplified in our cases is 
abundant, and will separate to a certain degree into three layers, — a 
mucous layer, brownish-gray serum, and a mucopurulent sediment. 
The sputum in these cases will gradually diminish leaving the patient 
apparently well, but certainly more susceptible to another acute attack. 

The acute exacerbations of a very chronic bronchitis form no small 
part of the admissions for acute bronchitis in a general hospital. 
These exacerbations may turn a dry cough to one with sputum, or a 
chronic expectoration of slimy mucus to an abundant mucopurulent 
sputum, often blood-streaked. 

During the acute exacerbations it varies much in appearance. Sometimes it is 
small in amount, very tenacious and purulent, sometimes of large amount, muco- 
purulent and slightly tenacious, and in still other cases, and perhaps most common, 
is an abundant white frothy seromucous sputum containing very little pus. The 
odor is sometimes foul, and in one of our cases almost putrid. The amount may 
vary from 100 to 200 cc. in twenty-four hours. Later the sputum increases in 
amount and presents mucopurulent flakes, sometimes very small. It separates into 
two layers, with the serum above and the solid particles below, while other cases 
will have a tenacious green mucus upper layer and a fluid lower layer. Micro- 
scopically are found pus, epithelium, and red blood-cells. The most common type 
of chronic bronchitis is the so-called winter cough, the patient during the winter 
suffering from cough and expectoration from which he is free during the summer. 



7U 



CLINICAL DIAGNOSIS 



This may be the history for fully twenty years. Later, however, the tendency is 
for the troubles to be continuous throughout the year. Such cases, as a rule, expec- 
torate only in the morning, and describe themselves as then " clear " for the day. 
Some such cases expectorate about an ounce of mucopurulent sputum, while in 
others it is in thick yellowish masses. In severe cases the cough is paroxysmal 
and the sputum a sticky, frothy phlegm, sometimes blood-streaked, and very hard 
to expectorate. During the acute exacerbations it is apt to become still more 
scanty and tenacious. In general, these patients feel best when the sputum is mod- 
erate in amount, and worse if diminished or increased. Microscopically, it contains 
much mucus, few pus-cells, except in the purulent variety, and much myelin. In 
some cases it is profuse, mucopurulent, the pus being present in nummular masses 
of a yellowish-green color which float in a liquid serum, thus causing it to separate 
into two layers. In other cases it may also be very large in amount but homoge- 
neous and extremely viscid, filling the cup with a single purulent glutinous jelly-like 
mass. 

Dry Catarrh. — The " catarrhe sec," in the sense of Laennec, is 
a disputed symptom-complex, but a chronic bronchitis with very little 
or no sputum is not at all unusual. According to the English, this 
occurs particularly in " gouty " patients. We associate it, however, 
more with emphysema and myocarditis. Some of these cases will 
deny any sputum whatever : in other cases it is glutinous and pearly. 

The chronic bronchitis of emphysema deserves especial mention, since it is 
such a common form. For instance, of 100 of our cases of chronic bronchitis, in 43 
per cent, the emphysema was a marked clinical feature. Of 100 cases of emphysema 
58 per cent, suffered also from bronchitis, and 47 per cent, from chronic bronchitis. 
Of the cases with chronic bronchitis, in 11 per cent, it was the dry form, the 
patient denying any expectoration whatever. In the cases with a slight sputum 
the expectoration occurred for years only in the morning, and for the most part 
consisted of a slight amount of bluish-white mucus. It may, however, be large in 
amount. One case, for instance, for years was awakened at five o'clock each 
morning with a severe paroxysm of coughing and expectorated large amounts of 
thick mucus, in an almost solid mass. In other cases the sputum is abundant, 
whitish in color, frothy, and amounts to one pint a day. In our cases of emphy- 
sema with chronic bronchitis and admitted during an acute exacerbation of the 
bronchitis the changes in the sputum, due to the acute exacerbation, were very 
varied. As a rule the amount increased very materially. In some cases it was 
very gelatinous, in some a white frothy mucus, in some a blood-stained serum, 
and in one case it became putrid. In one-fifth of the cases it was blood-streaked. 
As the cases improved it first became still more abundant, white and frothy, and 
then gradually diminished to the previous state. Among these sputa of chronic 
bronchitis a few may be mentioned in particular. In two a great many eosinophile 
cells were present. Some were remarkable because of the large amount of myelin, 
and in others large masses of fat globules were very noticeable. In one case of 
simple chronic bronchitis the man had had for ten or twelve years a slight expec- 
toration. On admission the sputum was thin, cloudy, and abundant, consisting of 
serum in which was a sediment containing moulds of the bronchi from medium 
size to 0.5 mm. in diameter, and consisting of mucus with pus and alveolar epithelial 
cells. The sputum also contained much pigmented alveolar epithelium, pus-cells, 
and red blood-cells. In a case of chronic bronchitis in an emphysematous person 
during a rather acute attack with a steadily elevated temperature the sputum was 
found to be considerable in amount, seromucoid, and never bloody in appear- 
ance, and contained during repeated examinations large numbers of sarcina?. In 
one case of chronic bronchitis with emphysema and " hay fever " the sputum was 
yellowish-green, mucopurulent, slightly blood-tinged, containing branched plugs 



THE SPUTUM 



71 



of the bronchi which consisted of mucus and pus in which were many eosinophile 
cells and masses of the mycelial threads of some mould. 

In the chronic bronchitis of cardiac disease, especially mitral, the 
sputum is characterized by the large amount of blood which may be 
present. This may be fresh or changed enough to give a prune- juice 
appearance, and in cases, particularly of mitral stenosis, may be 
grossly stained by the large numbers of Herzfehlerzellen which are 
constantly present. In other cases there is a daily large amount of 
frothy seromucous pus. 

Bronchorrhcea. — If by bronchorrhcea one means, with Laennec, 
a chronic idiopathic disease, the existence of this form is exceedingly 
doubtful. But if by the term is meant a chronic bronchitis with an 
abundant sputum, it is by no means rare. There is one form described, 
no example of which we have had in this hospital, of a " bronchor- 
rhcea serosa," or " asthma humidum," with an abundant, very watery, 
colorless, foamy sputum. Some of these cases are said to have a neu- 
rotic basis. In the bronchorrhcea of chronic bronchitis the sputum 
may be very large in amount ; commonly it is purulent, watery, of a 
green or a yellowish-green color, and in amount about 500 cc. a day. 
In these cases of " bronchoblennorrhcea" the bronchi have been denuded 
of mucosa and are lined by a pyogenic membrane, hence little mucus is 
secreted and the sputum is a profuse watery pus which separates easily 
in three layers and which may have a very bad odor, although not 
distinctly fetid. Such sputum is seen also in bronchiectasis, and per- 
haps in cases of putrid bronchitis and lung gangrene. 

Putrid Bronchitis. — In some cases of chronic bronchitis there is 
a disagreeable almost fetid odor to the sputum, but in putrid bronchitis 
a truly fetid expectoration is present. This occurs with most cases of 
bronchiectasis, gangrene of the lung, abscess, those in which the 
sputum decomposes within tuberculous cavities, and in empyema per- 
forating through the lung. A true simple bronchitis without dilated 
tubules and yet with a fetid expectoration is certainly very rare ( Fow- 
ler and Godley), while some deny that it ever exists (Hoffmann), and 
claim that the most of the cases thus catalogued are probably of bron- 
chiectasis. A case of putrid bronchitis would quite surely result soon in 
dilatation of the bronchi, and a case of bronchiectasis very often soon 
has a fetid expectoration. A very few genuine cases have, however, 
come to autopsy (Osier). 

The sputum is an abundant, profuse, watery pus, of a dirty ashy- 
gray or a brownish color, and with a horrible odor which sometimes 
will fill the whole house. Allowed to stand, it separates into three 
layers, — the upper of frothy air-containing mucus, usually small in 
amount, since the mucous membrane is for the most part destroyed 
and replaced by a pyogenic membrane, and hence secretes little mucus ; 



72 



CLINICAL DIAGNOSIS 



from this layer extend downward brownish strands. The middle 
layer is of serum, while the lowest is a thick sediment of epithelial cells, 
fatty cells, free fat, almost pure pus, all kinds of bacteria, and some- 
times Dittrich's plugs. No elastic tissue or fragments of lung are to 
be found, thus excluding gangrene. Gangrene, however, may follow. 
Chemically are found many of the products of decomposition of pro- 
teids, volatile acids, among them butyric, valeric, and others; NH 3 , 
H 2 S, leucin, tyrosin, etc. 

Fibrinous, Croupous, or Plastic Bronchitis. — By this term 
we here mean the chronic, idiopathic form, not the acute form occur- 
ring- in the course of certain infectious fevers (see pag _ e 24). This 
chronic form is a very rare disease as is shown by the fact that Bett- 
mann was able to find only twenty-seven cases in the literature of 
thirty-five years. This disease is very little understood. The sputum 
is for about five or ten days catarrhal, consisting of abundant mucus, 
and then after a severe coughing spell a bronchial cast is expectorated. 
Blood is quite often present in the sputum, either before or after 
the expectoration of the cast, but generally with it, and yet true hemor- 
rhage is rare. The frequency with which casts are expectorated varies 
much. Usually months intervene: but in some cases a cast is ex- 
pectorated every two or three days, or even every day, and in one case 
three were expectorated in one day. They are seen as formless masses 
in the sputum. After shaking them out in water they are found to be 
moulds of a bronchial tree. Those from the same case will often 
present exactly the same shape as if they were all from the same lobe. 
Sometimes they will appear to represent the tree of a whole lobe. 
The size of the largest of them is about 10 cm. long. Thev are gray- 
ish-white in color, contain a great many air-bubbles, and in about 
one-third of the cases are blood-streaked or contain a clot in the 
centre. On cross-section they are found to consist of concentric 
layers, apparent either grossly or microscopically ; the inner layer 
presents many whorls, since this layer, the oldest, has been telescoped 
into those more recently formed. The casts are usually hollow, 
although some are solid ; others are hollow in the larger branches 
and solid in the smaller, and still others vice versa. In the central 
layer, the oldest, are seen the remains of many cells, alveolar and 
bronchial epithelium, leucocytes, red blood-cells and bacteria. Some- 
times there is much fat in the casts and in the sputum. 

Casts do not always arise from nor are they produced by the epi- 
thelial cells of the mucosa, since in the above-mentioned case in which 
three were expectorated in one day, there was found to be no epithe- 
lium in that part of the bronchial tree. These were therefore a direct 
exudation. They were formerly supposed to consist of fibrin, since 
physically the material resembled this. Others claim that they are of 



THE SPUTUM 



7:: 



mucus, one says syntonin, another coagulated albumin, because of the 
chemical reactions. Some portions take Weigert's fibrin stain, but the 
most of it does not, hence it may be said that their composition is rather 
uncertain. Liebermeister 29 reviews the question at length as the result 
of the study of one fresh case and twelve museum specimens. He 
found fibrin and mucin present in seven of the thirteen cases. Wei- 
gert's fibrin stain cannot be trusted in these cases. For fibrin he pre- 
fers Kockel's method, and thionin for the mucin. In fibrinous bron- 
chitis the cast is of a loose texture containing much air, almost fills the 
lumen, and contains few cells. In diphtheria of the bronchi the cast 
consists of a firm hollow membrane of dense fibrin strands with count- 
less cells. A cast from a heart case at death was similar to those of 
fibrinous bronchitis. 

Charcot-Leyden crystals are commonly present in the cast. In the 
same sputum sometimes spirals are found. In Dr. Osier's case, men- 
tioned by Bettman, the ends of some branches of the casts were directly 
continuous with the central threads of true spirals. Many eosinophile 
cells are sometimes found, also red blood-cells, hgematoidin crystals, 
and lecithin granules. In Vierordt's case 30 there were many such 
casts, and on one occasion a typical Curschmann spiral. 

Bronchiectasis. — The sputum in the saccular form of this disease 
is often very characteristic; in the diffuse form not at all. In the 
former it is marked by two features, — its profuseness and the periodic- 
ity with which it is expectorated. This periodic feature was well 
shown in ten of our twenty-four cases. The expectoration occurs 
usually in the morning, and depends upon the position of the sac; an 
irritation of the bronchus due to a discharge of some of the contents 
of the sac caused by a change in attitude leads to a paroxysm of cough- 
ing and hence the emptying of the whole sac. The amount is profuse, 
as a rule, from 750 to 900 cc. in twenty-four hours, while in one of our 
cases it frequently exceeded one litre. Such profuse expectoration 
may extend over a considerable period of time. 

In general it may be said that the amount bears no relation to the duration of 
the disease, for one case of twenty-six years' standing expectorated but from 15 to 
30 cc. a day. Nor does it bear any relation to the size of the cavity, as was shown 
by one of our patients who expectorated more than one litre of sputum a day and 
yet at autopsy a few surprisingly small cavities were found. Of twenty-three cases, 
in two the sputum for twenty-four hours was under 100 cc. ; in eleven, from 1 to 
300 ; in two, about 500 ; while in seven, over 600 cc. It is stated that the diminu- 
tion in amount as the patient grows weak before death is surprising. 

The most characteristic sputum is grayish or grayish-brown in 
color, fluid, purulent, of a disagreeable odor, and separates into three 

29 Deutsch. Arch. f. klin. Med., 1904, Bd. 80, 5 and 6. 

30 Berl. klin. Wochenschr., July 16, 1883. 



74 



CLINICAL DIAGNOSIS 



layers on standing. This character, however, is by no means constant. 
A bronchiectatic cavity lined by mucous membrane will before in- 
fection secrete a pure clear mucus, but after infection has occurred, as 
is the rule, the mucosa is soon reduced to a pyogenic membrane which 
secretes a yellow purulent fluid with a sweetish odor. This may last 
for years. Sooner or later putrefactive changes may set in. The 
sputum is then mucopurulent, and of any shade of gray or green ; those 
with the worst odor in our cases were of a dirty gray color. If blood 
be present the color will present different shades of red or brown ac- 
cording to the chemical changes in the haemoglobin. While as a rule 
it is very fluid and watery, in some cases it is thick and viscid, while in 
other cases the sputum is mucopurulent and contains masses sug- 
gesting nummular In other cases, as was shown in our series, par- 
ticularly those improving under treatment, while it was profuse and 
watery at first, it later diminished in amount, was mucopurulent, and 
of a less offensive odor. The tendency to form three layers on stand- 
ing in a tall glass vessel was marked in fourteen cases. These layers 
are : an upper frothy mucous layer, a middle serous, and a lower granu- 
lar layer. From the upper often hang down through the fluid strands 
or " streamers," as they are sometimes called, of the same material. 
Hoffmann and others mention but two layers, omitting the upper 
mucous, which was absent in three of our cases. The lowest layer is 
always thick. 

In four of our cases there were four well-marked layers ; the lowest of an 
abundant, greenish-red, purulent material ; the one above containing a good 
deal of blood, and hence was red or brown ; over this a serous layer, while on 
top a frothy mucous layer. In other cases below the frothy mucous layer was a 
mucopurulent layer with streamers hanging down through the fluid and which 
with a little encouragement would probably all have sunk. The odor is, in 
general, bad, but in two of our cases it was not at all offensive. In some cases 
there is at first none, then a slightly offensive odor of a heavy, sweet nature, while 
after the putrefactive changes have set in it will be of a fetid character. These 
changes are due to secondary infections of the contents of the cavity. In ten of 
our cases the odor was heavy and sweet, while in ten others it was at some 
time very fetid. This is not exactly the same odor as in gangrene, but has 
been described in some cases as " pseudo-gangrenous," resembling the odor of rot- 
ten cabbage, or garlic. This odor will often diminish after creosote inhalations, or 
intratracheal injections, and a patient admitted with extremely fetid sputum may 
leave the hospitaLwith a much reduced sputum not at all offensive. The breath 
is sometimes worse than the sputum. The odor is largely due to H 2 S, NH 3 , and 
various volatile acids, among which are acetic, butyric, and formic. 

Hemorrhages into the cavity are common. Some put the figure 
at 50 per cent. They occurred in seventeen of our twenty-four cases. 
While slight, as a rule (eight cases), it is sometimes considerable (six 
cases), while in three of our cases it was extreme. In other cases it is 
fatal. 



THE SPUTUM 



7.") 



One of our cases, a man, was admitted to the hospital fourteen times, and five 
times because of extreme hemorrhage which threatened his life. At one of these 
admissions, in the course of a very few days he had six large and several small 
hemorrhages, reducing his blood rapidly from about normal to 1,090,000 red blood- 
cells with 20 per cent, of haemoglobin. In another case on one day 1700 cc. of blood 
were lost in about ten minutes. Another smaller hemorrhage the next day was 
fatal. 

Microscopical Constituents. — The cavity walls of an unin- 
fected case secrete mucus. If the outlet be closed, the cavity will con- 
tain mucus with desquamated epithelial cells. After infection, how- 
ever, the constituents are those of an abscess, since soon there is no 
mucosa and the walls are merely pyogenic membrane; after the 
fetid infection the elements are those of fetid bronchitis. The pus- 
cells, enormous in numbers, are well preserved, fatty, or vacuolated. 
The red blood-cells are unchanged or very much altered. It is rare 
to find elastic tissue, which would mean ulceration of the walls and 
was present in two of our cases. The fatty acid crystals occur espe- 
cially when the outlet of the cavity is small, thus allowing considerable 
stagnation. These crystals are often very large in size, numerous, 
and present a beautiful picture. They were abundant in four of our 
cases (see Fig. 6.) Cholesterin occurs; hsematoidin crystals, leucin, 
and tyrosin, sometimes ; Dittrich's plugs very commonly. The alveo- 
lar epithelial cells are usually present, containing pigment and, in 
some cases, much myelin or fat. No tubercle bacilli are found, but 
bacteria in great numbers in large zoogloea. Yeasts occur, and in one 
of our cases a definite aspergillus mould was found. In the contents 
of these cavities calcium salts are sometimes deposited, giving rise 
either to a clay-like mass or to the so-called " lung-stones." In two of 
our cases these lung-stones were present, and in one of them, a man 
who had expectorated several, at autopsy considerable calcareous 
concretion was found embedded in the walls of a cavity. The stones 
in the sputum were about the size of a split pea. 

In other cases, as in thirteen of our series, the sputum is by no 
means so characteristic, but presents all the characters of a chronic or a 
fetid bronchitis. 

In the bronchiectasis of children it is important to remember that 
all the sputum may be swallowed and vomited. 

Gangrene of the Lung. — In this disease the sputum most charac- 
teristic is profuse, extremely fetid in odor, of a greenish-brown color, 
separates easily into layers, and contains shreds of tissue. The latter 
point alone differentiates it from putrid bronchitis. Its odor is the 
worst of all, yet in some there is none whatever and no fetor of the 
breath. In five of our twelve cases the presence of gangrene was un- 
suspected, one case expectorating merely " phlegm.'' This odorless 
sputum is seen particularly in diabetics (in one of our cases it was an 



76 



CLINICAL DIAGNOSIS 



autopsy surprise), and in the insane. In cases of pulmonary embolism 
the infarcted area may become gangrenous and the sputum remain 
odorless until the necrotic tissue begins to be discharged through a 
bronchus. As a case improves the odor gradually disappears. 

The sputum of a case of pulmonary gangrene is profuse, watery, 
and usually of a dirty greenish-brown or ashy-gray color. But the 
color of those which contain blood will vary from reddish-brown to 
brownish-red according to the degree to which the haemoglobin is 
changed. Other sputa are described as chocolate in color. The sputum 
separates easily into three layers, — the upper of frothy mucus, the 
middle of serum, and the lowest, always a large one, of pus, tissue 
detritus, Dittrich's plugs, and tissue fragments. From the top layer 
streamers often extend clown through the fluid. In other cases the 
sputum is mucopurulent in nature. It may be viscid, lumpy, mixed 
with blood, and yet very fetid. 

Macroscopically of chief interest are the fragments of necrotic 
lung tissue. These vary from those most minute to fragments several 
centimetres long, of a sooty appearance, w;ith ragged outline, or sur- 
rounded by a grayish-yellow mass. These fragments are of firm tis- 
sue, or of colorless ground substance full of granular detritus or fat 
droplets, clumps of coal, large fat needles, bacteria, and elastic tissue. 
Dittrich's plugs are also found. The other constituents of the sputum 
are those of fetid bronchitis. There has been considerable dispute as 
to whether the presence of elastic tissue has any diagnostic importance. 
Some claim that it is rarely if ever present in this disease, and think it 
is digested by a ferment. Osier says that he has never seen a case in 
which it was absent. Dittrich's plugs were present in some of our 
cases, but Osier considers them rare. Alveolar epithelium, often 
pigmented, occurs ; fatty acid crystals and fat droplets are abundant ; 
cholesterin, leucin, ty rosin may be present ; masses of bacteria and of 
leptothrix occur, while flagellata have been described. In one case 
mentioned by Sahli, in which the infected area was non-odorous, large 
numbers of sarcinae were found. Blood is frequently present, and in 
large amounts. These hemorrhages are principally from small ves- 
sels, not from diapedesis. Fresh blood was present in five of our 
cases, but as a rule it is much altered and the haemoglobin present as 
methaemoglobin and haematin. 

Many observers have found acid-resisting organisms in the spu- 
tum of such cases (see page 51). Mayer found them in ten of fifty- 
eight cases. Many of these organisms are- probably to be classified as 
actinomyces (streptothrices) , and seem related to the timothy grass, 
the butter, et al, bacilli. They are not alcohol-fast. 

Abscess of the Lung. — In abscess of the lung the most character- 
istic feature of the sputum is the sudden appearance of a large amount 



THE SPUTUM 



7 t 



of quite pure pus in which are fragments of lung tissue. It may be 
many hundred cubic centimetres in amount. If allowed to stand it will 
present a certain layer formation, but not a characteristic one, since a 
slight shaking will restore its previous homogeneity. Its odor is at 
first faintly sweet like all pus, but when gangrene supervenes, as it 
often does, it becomes foul, yet less foul than that of the average case 
of gangrene and putrid bronchitis. The lung-tissue fragments are of 
particular importance. They are permeated by pus-cells which give 
them a yellowish-gray color. In size they vary from about a millet- 
seed to fragments even two inches long. They consist of a framework 
of elastic tissue, the remains of blood-vessels, masses of coal-dust, fat 
crystals, free fat, detritus, hsematoidin crystals, amorphous clumps of 
pigment, and zooglcea of cocci. In other cases there is a so-called " in- 
sensible disintegration " (Ley den) of the lung without the appearance 
of any large fragments. In such cases separate elastic fibres will be 
found. The other microscopical constituents are free elastic fibres, 
cholesterin, fatty acid crystals, free fat, lung pigment, detritus, bacteria, 
and haematoidin crystals, which may be present in large numbers and 
give to the whole mass of sputum a brown color. In the text-books, 
particularly of older writers, has been described the gross appearance 
of a sputum which escapes from a large cavity slowly through a small 
opening. In this case the pus as it escapes in a thin thread receives a 
mucous coating which prevents its coalescence. Hence the sputum 
when shaken out in water will appear like a skein or thread of pus. In 
our cases there has been no such appearance. 

The sputum of a liver abscess perforating through the lung is 
often characteristic. This sometimes causes also a lung abscess, in 
other cases an hepaticobronchial fistula without a local abscess. The 
sputum may have a so-called " anchovy-sauce " appearance, or the 
tint may be ochre-yellow due to the bile. The patient will complain 
of the bitter taste due to the bile acids. Microscopically bilirubin 
crystals and much elastic tissue will be found. 

In our records there is a series of seven such cases. In three the sputum was 
abundant, exceeding even a litre in twenty-four hours. Expectoration may be 
paroxysmal, even a quart at a time. The odor was mildly offensive in two, and 
markedly so in two others. In six of these cases the sputum presented the typical 
anchovy-sauce appearance ; that is, it was of a rusty brownish-red color, and 
frothy. In four cases it was blood-streaked, and in two purulent. Microscopically 
may be found the ordinary elements of sputum, pus, red blood-cells and alveolar 
epithelial cells. In addition the hsematoidin (bilirubin) crystals or needles may be 
a marked feature, as was true of two cases. Elastic tissue was found in con- 
siderable amounts in five cases, and at times was in considerable quantity. Fat 
crystals were present. In two cases the liver cells, it was thought, could be recog- 
nized. The living active amoebae were found in five cases, in one long before they 
could be found in the stools even after repeated examinations. It is interesting to 
note how often the sputum which contains the amoebae will also_ contain much 
elastic tissue. If the sputum be preserved in the thermostat, they will remain alive 
and motile for a day or so. 



7S 



CLINICAL DIAGNOSIS 



Abscess of the lung following acute lobar pneumonia. — In three of six 
cases there were no clinical features which would suggest this discovery at 
autopsy. In these cases the abscesses were small and multiple, and there was 
little or no sputum. In one case in which the diagnosis was not made the only 
change in the sputum was that the viscid tenacious blood-streaked expectoration 
became less tenacious. In one case a small amount of a very tenacious blood- 
tinged sputum became suddenly very dark, of a brownish-black color, mucopurulent, 
and then greenish and small in amount. It then disappeared, soon to reappear as 
a mucopurulent, very green, scanty sputum, and soon became large in amount, 
very thick, very purulent, and of a sour odor. It then became thinner, more 
watery, but blood-stained, containing elastic tissue. Then it reduced in amount, 
became mucopurulent, and finally, with the recovery of the case, ceased. In one 
case large numbers of trichomonads were in the sputum. 

Three cases of post-operative abscess were followed clinically ; one was 
admitted with a paroxysmal cough and the sudden expectoration of a foul-tasting 
sputum, which later became sweetish and of a less disagreeable odor [yet bad 
enough we thought]. The expectoration was large in amount, and contained pus 
and fatty acid crystals. There were large fragments evidently of tissue, even 5 by 
3 cm. in size, but so decomposed that the structure could not be well made out. 
The sputum then became less profuse, mucopurulent, and the patient recovered. 
In another case the sputum was very foul and contained much fat, while in the 
last case it was large in amount, foul, purulent, and blood-streaked. Of two other 
cases, in one the sputum did increase, but the diagnosis was not made, while in the 
other an abundant, blood-streaked, brownish sputum of no especial odor suddenly 
increased in amount, became dirty, frothy, and foul, slightly streaked with blood, 
and separated easily into three layers. At autopsy a large abscess cavity was 
found. 

Perforating Empyema. — The sputum of these cases resembles ab- 
scess of the lung, with the exception that there is less elastic tissue and 
practically no tissue fragments. There will be many haematoidin and 
other crystals. The odor, that of pus at first, in some cases described 
as resembling old cheese, is soon vile because of the infection which 
commonly follows. In case the pleural fluid escapes slowly through 
a small opening, it is said that there may be present the- fibrillary 
nature of the pus seen when an abscess is discharged, and due to a 
coating of mucus around the thread of pus. When the opening is 
large the pus will escape often rapidly, yet without causing pneumo- 
thorax. Allowed to stand, it separates into three layers, — the upper 
of mucus, the middle of the pus serum, and the lowest of pus-cells. 

Perforating Serous Pleurisy. — This is exceedingly rare. The 
sputum is like that of oedema of the lungs, but contains more albumin, 
becoming even solid on boiling. 

The Serous Sputum of CEdema of the Lungs. — In these cases 
there are expectorated large amounts of a frothy, cloudy, colorless, or a 
slightly bloody sputum which on standing separates into three layers : 
an upper abundant frothy layer, a foamy fluid, and a lower thin layer 
of pus together with the elements of the pre-existing sputum. Except- 
ing in cases of pneumonia, etc., it is largely quite pure serum, which is 
frothy since it is so rich in albumin, watery, since directly from the 



THE SPUTUM 



7!) 



blood, and contains only a trace of mucin. Cases presenting this 
sputum are common enough, and the appearance of this stream from 
the mouth and nostrils is one of the most gruesome sights of the sick- 
room. 

The Albuminous Expectoration of Thoracentesis. — Of the recent 
articles, the student is referred to Riesman 31 and Allen. 32 This con- 
dition follows a thoracentesis in which the fluid withdrawn has been 
large in amount and rapidly removed. Terrilon has grouped the cases 
into three classes. The first is of mild cases, the sputum little to 800 cc. ; 
the condition of the patient is always good. The severe cases are 
accompanied by dyspnoea and collapse, and an expectoration of from 
1200 to 1500 cc. The grave cases are marked by a sudden onset; the 
fluid may gush from the mouth and the patient die at once from suffo- 
cation from the fluid which he cannot expectorate rapidly enough, or, 
indeed, he may die before he expectorates any. As a sequela of thora- 
centesis it is rare. 

The onset is, as a rule, in less than one hour, or it may come on 
during aspiration. The latest case began eighteen hours after the 
tapping, and lasted for twenty-four hours. The duration may be 
from several hours to a day, but as a rule it is from one to two hours. 
The fluid is richly albuminous and hence viscid, frothy, and neutral 
or faintly alkaline in reaction. Chemically it may be tested by heat 
and nitric acid, or by nitric acid alone, or by potassium ferrocyanide. 
The sputum should be diluted and filtered and the filtrate tested. 
Acetic acid gives a precipitate of mucin. It also contains urea, haemo- 
globin, and the various salts of blood-serum. Urobilin has been found. 
The amount is generally from 200 to 900 cc. Two litres have been 
expectorated. On standing it separates into three layers, — the upper 
whitish and frothy, the middle opalescent and yellowish or greenish, 
the lower more viscid, containing a few whitish flocculi, and some- 
times slight traces of blood, but rarely much. In Riesman's case there 
was no lower layer, the specific gravity was 1018, the fluid became 
solid on heating, the total solids were 5.84 per cent. In Allen's case 
reported from this clinic the expectoration began in half an hour after 
3100 cc. of pleural fluid had been removed, and lasted four hours. It 
was about one litre in amount, frothy, pale green in color, with a 
muddy sediment. Microscopically were found flat epithelial cells, a 
few leucocytes and red blood-cells, and many bacteria. The analyses 
differ widely. The fluid, while sometimes resembling that of the 
pleural exudate, in some analyses differs considerably from it. The 
cause has been much disputed. The majority of writers think that it 
is due to an acute oedema of the lungs, the result of their rapid ex- 

a Amer. Jour. Med. Sci., April, 1902, p. 620. 
"Johns Hopkins Hosp. Bull., January, 1903. 



80 CLINICAL DIAGNOSIS 



pansion, but the mechanism of which is very much disputed. We 
would call attention, however, to certain cases occurring during para- 
thoracentesis and followed by pneumothorax. Some of these cases 
suggest the expectoration of the pleural exudate, and the demonstra- 
tion that in many cases the two fluids differ does not disprove the claim 
that in certain the fluid does come from the pleural cavity. 

Haemoptysis. — For the causes of pulmonary hemorrhage we will 
give a summary of the chapter on this subject in Osier's text-book. 

Haemoptysis may occur ( i ) in young healthy persons without 
known cause and without subsequent symptoms. (2) As the first 
symptom of pulmonary tuberculosis, or (3) in a well-marked case. 
During the early stages it is due to mucous erosions and diapedesis; 
later to the rupture of an aneurism in a branch of the pulmonary 
artery, which is exposed by cavity formation. (4) Other diseases of 
the lungs, and this list includes practically all pulmonary disease. 
Among them are pneumonia at the onset, " bloody bronchitis," cancer, 
gangrene, abscess, bronchiectasis, tumors, cysts, and actinomycosis. 
(5) Heart disease, especially mitral. As a rule slight, yet it may be 
profuse and recur for years. (6) Vascular degeneration, the result of 
increased pulmonary tension, seen in emphysema and arteriosclerosis. 
(7) In ulcerations of the larynx, trachea, and bronchi it may be pro- 
fuse and rapidly fatal. (8) In aneurisms it is sometimes sudden and 
fatal; in other cases the so-called " weeping" may persist for weeks, 
or the pressure of the aneurism as a tumor may cause an erosion of 
the mucosa. (9) An extremely rare form of vicarious hemorrhage 
due to interrupted menstruation. (10) In rheumatism, (n) Malig- 
nant fevers, the so-called hemorrhagic type. (12) Purpura hemor- 
rhagica and various other blood diseases, among which are haemo- 
philia, leukaemia, and scurvy. (13) Distomatosis ( Westermanii) . 

The amount of the blood may vary from a mere speck or a few 
small clots to a quart or more. In general it is of a bright red color 
even when of venous origin since it is aerated in the lungs, frothy 
from its admixture with air, and always coughed up. When it clots 
in the bronchi, casts of these may be formed. In gastric hemorrhage, 
as a rule the blood is dark, due to the transformed haemoglobin the 
result of the action of the acid gastric juice, not frothy, partly coagu- 
lated and vomited. Such points are easy enough to determine when 
the doctor is the observer, but from the history given often difficult, 
for in their anxiety the friends will not notice such fine points. The 
severe coughing often causes vomiting, while the coughed blood may 
be swallowed and vomited. Aspiration of blood from a gastric ulcer 
will also cause a certain amount of coughing. The gastric blood 
may be bright if the stomach be empty and a large artery be opened, 
while the pulmonary blood may be dark and not frothy, provided a 



THE SPUTUM 



81 



large branch of a pulmonary artery be eroded. A most important 
point in determining the origin of the blood is the history of the case, 
whether of previous lung or stomach trouble. Subsequently in a case of 
haemoptysis the sputum will for some days be blood-tinged. In case 
the hemorrhage was from the stomach, there is usually considerable 
blood in the stools, but a small amount of blood could be explained as 
that swallowed. It is important to recognize the so-called spurious 
haemoptysis, in which case the blood may arise from varicosities of the 
veins at the back of the tongue or lesions in the throat, glottis, or 
oesophagus. It is said to be common for young anaemic girls to com- 
plain of hemorrhage in the morning which has as its source the spongy 
gums. 

Haemorrhagic Infarction. — In many cases this diagnosis may be 
made from the inspection of the sputum alone. This is in discrete 
masses which remain isolated in the cup, and which appear to be pure 
blood, but are found to consist of a very tenacious mucus which is 
intimately mixed with pure fresh blood. In other cases these balls will 
be of a glairy mucus, with considerable blood-streaking. Expectora- 
tion begins at once with the cough and the pain, the character of the 
previous sputum changing considerably at this time. Such was true 
of half of our cases. Microscopically, the mucus and the red blood- 
cells form the most of the mass, and leucocytes are remarkably few 
in number or even absent, while alveolar cells loaded with blood pig- 
ment are usually present in enormous numbers. This, however, may 
be explained from the fact that these infarctions are particularly com- 
mon in mitral disease. In other cases the sputum is much less char- 
acteristic, as is often seen in cases in which there was considerable 
previous to the embolism. Sometimes it is a real hemorrhage. Such 
was true of one-third of our cases. Sometimes the sputum is pneu- 
monic in character. In other cases it resembles the brick-red 
sputum of chronic passive congestion. In such the diagnosis is said 
to be hard. In one-fifth of our cases there was practically no sputum. 
In one, however, the patient remembered some blood-streaked sputum 
before admission to the hospital. 

The above-described character of the expectoration is soon lost, in 
a very few days sometimes, but usually in about one week the sputum 
is merely blood-stained and will soon be free from blood. With 
recovery also it becomes more watery. The amount of blood certainly 
bears no relation to the 'size of the infarctions. This was well seen 
in one of our cases with very large infarctions and only slightly blood- 
streaked sputum. 

Chronic Passive Congestion. — In chronic passive congestion, espe- 
cially due to mitral disease and particularly stenosis, the sputum is 
characteristic. The expectoration is chiefly in the early morning, and 
6 



82 



CLINICAL DIAGNOSIS 



consists of a white mucous background, colored by dots or streaks 
of a rusty color; or the whole mass may be uniformly rusty. These 
dots, streaks, or uniform tinting are due to the large masses of Herz- 
f ehlerzellen ; that is, to the alveolar epithelial cells laden with golden 
yellow granules of amorphous pigment derived from the red blood- 
cells which have escaped into the alveoli by diapedesis. It is in this 
condition that the large number and the constant presence of these 
cells have a great diagnostic importance. This importance was im- 
pressed upon us by one case which I will mention in detail. The man 
spoke only a language for which we could obtain no interpreter; a 
history of his case was therefore out of the question. His heart was 
repeatedly examined and reported practically negative. The sputum, 
however, contained constantly large numbers of Herzfehlerzellen. 
The pleural exudate was hemorrhagic and contained mulberry-like 
masses of the proliferated endothelium of the pleural cavity. He died 
in a few days without a diagnosis. At autopsy there was found a 
mitral stenosis of an extreme degree, one of those cases common 
enough without any heart murmurs, and several large pulmonary in- 
farctions. 

Malignant Disease of the Lungs. — The sputum of this has in some 
cases been described as " characteristically gelatinous, of a red or 
blackish-red color like currant-jelly," but this is by no means common. 
In other more common cases it has a prune- juice character. A grass- 
green or an olive-green sputum has also been found resembling that of 
caseous pneumonia. A prune- juice sputum (present in ten of eighteen 
cases) Stokes thought an important sign. In any case a search should 
always be made for the fragments of the tumor. Our cases presented 
no important points. In one case of secondary metastasis into the lung, 
although the area involved was large, there was practically no sputum. 
In another case of a large tumor the sputum was very viscid, slightly 
rusty, of a greenish-red color, not fetid, and consisted of pus, red 
blood-cells, and alveolar epithelium with much myelin degeneration. 
The next day it was of a dirty grayish mucopurulent character, and at 
times contained considerable blood. In the case of an epithelioma of 
the bronchus there was considerable expectoration and several severe 
hemorrhages. At other times the sputum was seropurulent, liquid, 
blood-streaked, not tenacious, and frothy. Diagnosis has in several 
cases been made from the tissue fragments in the sputum. 

In mediastinal growths the expectoration is due to the bronchitis 
resulting from the pressure, and will present the various characters 
of this condition. If, however, the size of the tumor causes a nar- 
rowing of the bronchus, this may lead to bronchiectatic cavities, 
and a profuse fetid expectoration be the result. Gangrene may 
supervene. 



THE SPUTUM 



83 



Syphilis of the Lung.— Fowler and Godley state : " Evidence of 
excavation with fetid expectoration which does not contain tubercle 
bacilli should always suggest the possibility of the case being one of 
pulmonary lues.'' The expectoration may be profuse, purulent, and 
offensive, fetor being a common characteristic in advanced cases. 
With stenosis of the bronchus, a common event in this disease due to 
the extensive formation of connective tissue at the hilum of the lung, 
bronchiectatic cavities will form and the sputum present all of the 
characters of this condition. While hemorrhage is not common, some 
cases attract attention by the remarkably bloody nature of the sputum. 
Some writers state that unless repeated examinations for the tubercle 
bacilli be made, these cases will pass for consumption. Osier, on the 
other hand, states that he has never seen a case which resembled 
tuberculosis clinically. 

Pneumonoconiosis. — According to the dust which is inhaled this 
condition has received various names, — anthracosis, if it is coal-dust ; 
siderosis, if iron dust; and chalicosis, in which it is a silicate or other 
rock-dust. The expectoration is in general mucopurulent, often pro- 
fuse, and laden with the above-mentioned dusts (see page 21). 

Diphtheria. — Cultures should be made from the throat of all those 
patients concerning whom the question arises whether they have or 
have had diphtheria. Cultures should certainly be made if there is 
any membrane visible, but also if the throat of one known to have been 
exposed to diphtheria shows a follicular tonsillitis, or even if only con- 
gested. If a person known to have been exposed has any constitutional 
symptoms suggesting infection, the bacteriological examination of the 
throat should be made even though it appears perfectly normal. Ex- 
aminations should be made at frequent intervals after an attack of 
diphtheria until two successive examinations fail to demonstrate this 
bacillus. Also the nasal secretions o-f all persons with chronic coryza 
who have been exposed to diphtheria should be examined. Cultures 
should be made from any membrane forming on a superficial wound 
in the skin or on any mucous membrane. The reason for these care- 
ful examinations is not nearly so much for the sake of the patient as 
for the safety of his neighbors. 

Cultures and smears are best made from fragments of the mem- 
brane itself. If a shred cannot be picked from the surface with a 
pair of forceps, material for the culture can be obtained on a swab 
made up of a wad of cotton wrapped on the end of a stiff wire about 
eight inches in length. This is put into a test tube, cotton end in, 
the free end sticking out, the tube closed with a cotton plug and then 
sterilized. Cultures should not be made from the throat within two 
hours after an antiseptic gargle has been used. 

This sterile cotton swab is forcibly rubbed against the edge of the 



8-i 



CLLNTCAL DIAGXOSIS 



patch of membrane when this is visible, and when there is no mem- 
brane present, against any exudate or over any injected area. Smears 
are then made from fragments of membrane or from the swab, and 
the swab is then rubbed forcibly and thoroughly over the moist surface 
of solidified blood serum. Failures to cultivate the bacillus are fre- 
quently due to the fact that the swab was rubbed over the centre of 
the patch of membrane, or not forcibly enough, and that the surface 
of the serum was too dry, or that the swab was not sufficiently rubbed 
against the serum. 

The serum tube is put into the thermostat as soon as possible and 
left there at 37 0 C. for from eight to twenty hours. Smears are 
then made from the growth. 



Bacillus diphtherias, or the Klebs-Loffler bacillus, is a small straight 
or slightly curved rod, from one to six, average two or three microns 
in length. It is a non-motile, non-liquefying, non-spore-producing 
aerobe. It grows on all ordinary culture media, providing they are 
not acid nor too alkaline, but best on blood serum. 

One of the best media is LoMcr's blood serum. This is a mixture of blood 
serum three parts, bouillon containing one per cent, of glucose, two parts. It 
is coagulated at about 70°C. When no tubes of media are at hand, cultures can 
be made on the coagulated white of a hard boiled egg. The shell is lifted at one 
end of the egg, the surface inoculated and the shell put back. The egg is then 
put in a thermostat. 

Bacillus diphtherias grows with great rapidity on the above men- 
tioned serum. At the end of even eight hours in some cases the 
growth can be seen and the organisms easily found in smears, but a 
negative examination at that time has no value. In any case the 
growth can be determined in 18 or 20 hours. Until this time the 
diphtheria bacillus has dominated, and smears from the surface of 
the serum look like pure cultures. After this time, however, the organ- 
isms from the throat may begin to dominate and soon crowd out the 




Fig, 19. — Bacillus diphtherise, from a young blood serum culture. 
Pnotomicrograph by Dr. Thomas M. Wright, 



THE SPUTUM 



85 



diphtheria bacillus, unless the latter was present in pure culture in 
the throat. The colonies of Bacillus diphtherise on blood serum are 
moderate in size, elevated, of a grayish-white color and with opaque 
centres. 

This organism when properly stained presents an almost charac- 
teristic appearance. Smear preparations for microscopic examination 
are made by scraping some of the growth from the surface of the 
serum with a platinum needle. This is then rubbed on a glass slide, 
allowed to dry in the air, and the slide passed through a flame three 
times, in order to fix the specimen. 

A good stain is Loffler's Methylene Blue (saturated alcoholic solution of 
methylene blue 30 cc, aqueous solution of potassium hydrate, 1:10,000, 100 cc). 
The slide is covered with this stain and warmed for a few minutes (it will not 
overstain), the stain is then washed off in running water and the specimen dried 
with blotting paper. The specimen can be improved by washing it further with 
0.1 per cent, acetic acid, but this is seldom necessary. 

Bacilli stained in this way show at their ends or along their 
bodies deeply staining granules called " polar granules " which appear 
as deep blue dots. In many there are several such granules, giving 
the organism a beaded appearance. 

Ncisser's stain is supposed to differentiate this organism from all others and 
is adopted as the standard in clinical work. The specimen is stained for about 
five minutes with a methylene blue solution. (Methylene blue, Griibler, 1 gm., 
96 per cent, alcohol 20 cc, distilled water 950 cc, glacial acetic acid 50 cc.) This 
stain is filtered before using. During the staining the dye should be frequently 
renewed and the specimen gently heated. The specimen is then washed in water. 
It is next stained in Bismarck brown solution for. two minutes. (Bismarck brown 
2 gm. dissolved in 1000 cc. of distilled water.) The pole granules are stained 
a deep blue and the bodies of the bacilli a light brown color. 

Gram stain. — The smear is stained for one and, a half minutes with aniline- 
gentian-violet. (Saturated alcoholic solution of gentian violet 5 cc, aniline 
water 100 cc. The aniline water is made by slowly mixing aniline oil 1 part with 
distilled water 20 parts. The mixture is allowed to stand for some hours and 
then filtered until clear.) It is then washed in water, and then put for one or 
two minutes in Gram's or Lugol's Iodine solution. (Iodine 1 part, potassium 
iodide 2 parts, water 300 parts.) The specimen is then washed in absolute alcohol 
for three to five minutes. It is then mounted. Or it may be counterstained with 
Bismarck brown, washed and dried, and mounted. Bacilli which " stain by Gram," 
or are " Gram positive " retain the purplish hue derived from the gentian violet. 
Those which " decolorize by Gram " or are " Gram negative " will appear unstained 
unless a counter-stain is used, in which case they take the color of the counter-stain. 

Bacillus diphtherise is characterized, in addition to its manner of 
growth already mentioned, by its irregularity in staining, and its 
irregularity in size and shape. Its irregularity in staining is shown, 
by its polar granules or beaded appearance, but this depends in part 
on the age of the growth and may entirely fail. These bacilli vary 
much in size. Some recognize a " long " form and a " short " form 
and think these forms differ in virulence. But no relation between 



86 



CLINICAL DIAGNOSIS 



length and virulence has been determined. The length seems to depend 
rather on the stage of the disease when the culture is made and the 
age of the growth. 

For the clinical laboratory examination, smears are made directly 
from the throat and blood serum is inoculated. The growth on the 
serum is examined in less than twenty-four hours. From these two 
sets of smears, those directly from the throat and those from the 
serum, both stained by Neisser's method, the diagnosis is made. The 
smears from the swab may show diphtheria bacilli and no growth be 
obtained, and frequently the growth will succeed when the search over 
the smears was negative. 

One looks especially for bacilli about five microns long with brown 
bodies and two blue staining polar granules, one at each end, in the 
presence of which a positive diagnosis of diphtheria may always be 
made. Hosts of other shapes and forms may be seen, but the presence 
of this form decides the question. The barred and beaded forms are 
not as common as these with the two polar granules, which are 
present in most localities in over 90 per cent, of the cases. If the 
initial culture be older than twenty-four hours, these forms may not 
be seen. One may then find the host of involution forms with their 
bizarre shapes: spindle, pear, dumb-bell, lancet-club forms and the 
varicosed forms. These might be found in the smears made immedi- 
ately from the throat, but they could not be told from involution 
forms of other mouth organisms. 

If the organism be cultivated for several generations it rapidly 
loses its characteristic morphology and can then not be accurately 
differentiated from other bacilli. For these reasons the clinical labora- 
tory diagnosis of diphtheria is made from the examination of the 
smears made directly from the throat and those from the twenty- four 
hour, or younger, culture. If the typical forms are not found in 
these, it is better to make a fresh bacteriological examination than 
to cultivate the original culture further. 

In addition to Bacillus diphtherias, one often finds in the throat 
Micrococcus aureus and Streptococcus pyogenes. 

The value of the bacteriological examination of the throat is 
emphasized by the fact that McCollum was able to grow the organism 
from the throats of 40 per cent, of 500 cases whose throat condition 
suggested, but was not characteristic of, diphtheria, and that in many 
instances positive cultures were obtained from 24 to 48 hours before 
any membrane appeared. 

The statement is often made that Bacillus diphtherias can be 
found in the throats of healthy persons who have not been exposed to 
diphtheria. McCollum states that Loffier found them in 4 of 160, 
Park and Beebe in 8 of 330, Kober in 5 of 600, Denny in 1 of 235, and 



THE SPUTUM 



87 



he in none of 130 such persons examined. He also doubts that it 
is often found in the throats of healthy persons who have been exposed 
to this disease, since he failed to find it in any of 60 nurses from the 
diphtheria wards of the Boston City Hospital. While it is possible 
that some of the earlier reports were made before the question of 
pseudo-diphtheria bacilli had arisen, it is undoubtedly true that the 
Bacillus diphtherias can live for a long time in the throats and noses 
of those who have recovered from an attack of diphtheria. 

The test of its virulence is often important for the recognition of 
the diphtheria bacillus. A guinea pig is inoculated subcutaneously with 
a bouillon culture of the organism in question. This culture should 
not be over 48 hours old, since its virulence tends to diminish after 
that time. The amount injected should equal 1 per cent, of the 
animal's weight. If the organism injected be Bacillus diphtheriae, the 
animal will show symptoms of acute or of chronic infection. If 
the infection be acute, the animal will die in from one to six days. 
At the seat of inoculation will be found extensive necrosis with a 
marked inflammatory reaction. There will be extensive oedema of the 
abdominal wall, effusions into the serous cavities, hemorrhages into 
the adrenals, swelling of and hemorrhages into the lymph glands, and 
focal necroses in the various organs. 

If the injection cause a chronic infection, the animal will show 
paralysis similar to that in man, and will die in about six weeks. 

Formerly all organisms with the morphology described above 
were considered Bacillus diphtheriae. Since then various pseudo- 
diphtheria bacilli have been described, and the relation of these to 
Bacillus diphtheriae is still a mooted question in bacteriology. 

The following groups of organisms may be mentioned: 

1. Bacilli with the typical morphology, typical cultural charac- 
teristics, especially the ability to form acid from glucose, and which 
produce the typical lesions in animals, are in the opinion of all obser- 
vers Bacillus diphtheriae. 

2. Bacilli with typical morphology, and typical cultural reactions, 
especially the ability to form acid from glucose, but which are not 
pathogenic to animals, may be called avirulent diphtheria bacilli. 
Roux maintains, however, that the ability of the organism to fer- 
ment the sugars is not an essential characteristic of the species. 

3. Bacilli with typical morphology, but which do not conform 
in their cultural reaction with the diphtheria bacillus and which are 
either non-pathogenic to animals, or do not produce typical lesions, may 
properly be called pseudo-diphtheria bacilli. 

4. Finally, there are a number of organisms which resemble 
Bacillus diphtheriae in many ways, but whose morphology is not 



88 



CLINICAL DIAGNOSIS 



exactly the same, since they do not show bipolar staining and are 
often shorter and a little thicker than the typical form, and which 
have different cultural characteristics and differ in their pathogenicity. 
This group certainly includes the pseudo-diphtheria bacillus of Hoff- 
mann, the xerosis bacillus, and others. 

But for the clinical laboratory worker this classification has little 
interest. He should work with fresh smears and cultures less than 24 
hours old. If he calls all organisms with a characteristic morphology 
Bacillus diphtheria?, his mistakes will number less than one in a 
hundred. This odd case will not be hurt if treated for diphtheria, 
and the community will be safer if no chances are taken. 



Vincent's Angina, " Plaut's angina," '* ulceromembranous 
stomatitis," and " ulceromembranous angina," are some of the names 
applied to acute or subacute febrile infections of the tonsils or mouth, 
characterized by the formation of deep penetrating ulcers often covered 
by a pseudomembrane, and the presence in smears made from the 
base of these ulcers of large numbers of certain bacteria. 

The base of the ulcer is mopped with a sterile cotton swab and 
smears at once made, dried, run through the flame three times, and 
stained with carbolfuchsin. 

Carbolfuchsin. — Basic fuchsin 1 part, absolute alcohol 10 parts, 5 per cent, 
carbolic acid, 100 parts. The specimen may be covered with the concentrated 
stain for about half a minute, or, better, this stain diluted with from five to ten 
times its volume of water and then left on for about five minutes. 




Fig. 20. — Smear from the throat of Dr. Louis P. Hamburger's case of Vincent's angina. 
Photomicrograph by Dr. H. Schapiro. 



In typical specimens the field will be found crowded with various cocci and 
bacilli, and especially with Bacillus fusiformis and a spirochete. Bacillus fusi- 
formis (Vincent) is a long slender bacillus often fusiform in shape, the ends being 
quite pointed. It is straight as a rule, but many are curved, and a few may be 
S-shaped. It is non-motile (disputed), decolorizes by Gram (disputed), is often 
beaded, and can be grown in pure culture (Weaver and Tunnicliff, Jour, of 
Infect. Dis. } 1905, ii. p. 446). 



THE SPUTUM 



This organism has been found in many normal mouths, on the surface of 
normal tonsils, in the cavities of decayed teeth, in the exudate of pyorrhoea 
alveolaris, in antrum disease, aphthous ulcers, but also in fetid abscesses almost 
anywhere in the body. The organism is common enough but has escaped notice 
since it is with difficulty grown, and when seen in smears is usually passed by as 
a " harmless saprophyte." Recent work is rather in favor of the view that this 
organism is pyogenic. 

In the mouth this organism is often but not always associated with a spirillum 
or spirochete, which is from 15 to 25 microns long, shows from two to five spiral 
turns, is actively motile, is Gram negative, and stains so faintly that it is often 
overlooked. It has not been cultivated. This is quite certainly a saprophyte 
which occurs in enormous numbers in the mouths of even healthy persons, and 
yet it is so frequently associated with Bacillus fusiformis that the two are supposed 
to be symbiotic and together to cause the ulcers. 

These few lines concerning Vincent's angina are not inserted so 
much because of any importance of the disease as a separate disease, 
for this question is a disputed one, but rather to emphasize the impor- 
tance of the student's studying the flora of the mouth. The number of 
organisms there is great — over one hundred different forms have been 
found. Among them are those which are so constant that they are 
considered the natural mouth-flora, bacilli, spirilla, and various lepto- 
thrix and spirochsete forms, many of them huge, many showing 
grotesque involution forms, and all with one common characteristic, 
that they are very hard to cultivate. i\mong these, most believe, are 
Bacillus fusiformis and spiroch?ete dentalis (Miller) ; whether any 
of these are pathogenic or not is a question, but one thing is certain 
that they increase in great numbers in any ulcerative process in the 
mouth and probably do aid in the tissue destruction. Certain it is 
that they aid decomposition of the exudate in these ulcers, and 
explain much of its bad odor. It is very likely that Bacillus fusiformis 
is important in the production of Vincent's angina, but it is interest- 
ing to hear the discussion aroused in the demonstration of a slide from 
such a case, fairly well covered with fusiform bacilli and spirochsete. 
For smears from ill-kept mouths without any deep ulcers will show 
such remarkable pictures that the smear from the base of an ulcer must 
be very rich indeed in long bacilli and spirochaete before many will 
grant it any importance in the diagnosis. 



CHAPTER II 



THE URINE 

y 

GENERAL CHARACTERISTICS 

The Collection and Preservation of Urine. — It is of the utmost 
importance in all chemical examinations of the urine that a complete 
and well-mixed twenty-four-hour specimen be obtained, so much 
do the various voidings of the day differ. To accomplish this most 
patients need to be watched, and one must rely much on the attention 
of nurses and orderlies. 

In this clinic the day's collection begins at about 6 a.m. The 
patient voids at this hour, and the urine is collected from then 
until 6 a.m. the next day including this hour's voiding. In case we 
separate the urine of the day and the night, the former period extends 
from 6 a.m. to o, p.m. ; the remaining hours are those in which the 
patient is, as a rule, asleep. 

It is very essential that a clean bottle be employed and some means 
used to prevent the very rapid bacterial action. There is no one 
preservative which is good in all cases, and the worker should choose 
his agent with reference to the use to which he expects to put the 
urine. For instance, for chemical work we usually use chloroform, 
enough so that several drops remain at the bottom. The bottle must 
be tightly corked or bacteria will certainly grow in the upper layers 
from which the chloroform is volatilizing. We prefer this, since it 
adds nothing to the volume and can be entirely removed. The dis- 
advantages of it are that the formed elements are not well preserved 
for microscopical examination, although crystals are, and that certain 
chemical changes do result, whereby, for instance, a' suggestive sugar- 
test with Fehling's can be obtained in urine thus preserved; yet even 
for oxybutyric acid determination the urine may be kept unchanged 
even for years. A few crystals of thymol are often used. A slight 
objection to this is that the urine will give a test similar to bile. 
Gum camphor is very commonly used. Formalin is of value to pre- 
serve microscopical constituents. A person must be wary in a chemical 
examination of such an urine, since formalin is an active reducing 
body, and the diagnosis of glycosuria has been made. Other workers 
employ a dilute chloroform water or a saturated borax solution, add- 
ing one-fifth volume to the urine. The specimens, however preserved, 
should be kept in an ice box. 

Sometimes a twenty-four-hour specimen is not desirable. For 
instance, in the diagnosis of slight chronic nephritis a comparison of 

90 



THE TfcRINE: AMOUNT 



the urine first voided and that voided at the end of a day's work gives 
valuable information, also in a suspected case of cyclic albuminuria. 
Again, in diabetes mellitus of a very mild degree the urine voided three 
or four hours after a hearty carbohydrate meal may contain sugar 
sufficient for a positive test, while if this voiding be diluted by mixing 
it with the whole twenty- four hours' amount the sugar percentage 
would be too small to be detected. For microscopical examination the 
urine should be tested as early as possible after voiding, and, if pos- 
sible, without the addition of any preservative. Formalin is said to 
add a crystalline component to the sediment (May). 

The value of urinary diagnosis as a routine practice cannot be too 
strongly emphasized. About fifteen minutes are sufficient to find out 
if anything unusual demands further attention. The doctor or stu- 
dent who employs the " X-ray test" or the " sink test" is a traitor, 
and should be treated as such. 

The unexpected is found quite often, and the perfectly healthy ap- 
pearance of the patient is no guarantee that the urine will not clear up 
the case. The surgeons especially need this warning. A recent case 
was a lesson, for one urine examination would have probably pre- 
vented an operation following which the woman went into diabetic 
coma and died. 

The Amount of Urine. — The limits of the amount of urine to be 
considered normal vary widely, both for individuals, and depending 
upon this, for different countries, especially those in which the customs 
are fairly uniform. In general it depends on the amount of water in 
the food and of solids in the blood, especially salts, to be excreted, their 
excretion increasing the water output. The limits usually given are 
from 1 500 to 2000 cc. That may be true for a country in which beer- 
drinking is very common ; it is, however, too high for others, as for 
this, where from 900 to 1200 are more common figures. For France 
the figures 900 to 1500 are given (Becquerel). In women the output 
is slightly less than in men. The amount of urine also depends on the 
size of the person ; in an adult it is almost directly proportional to his 
weight. This is not true in the case of children, who excrete relatively 
more than do adults ; newly born infants, from 1 50 to 200 cc. a day, 
and children from three to five years of age, about 700 cc. 

The amount depends chiefly on the volume of fluids consumed. 
The extreme physiological limits, depending chiefly upon this, are 
from 800 to 3000 cc. The increased output reaches its maximum in 
from two to three hours after drinking a large amount of water, and 
is over in from five to six hours. Yet, as several have shown and all 
experienced, the water output is perhaps the most capricious of all 
the urinary constituents, and the water ingested is only one factor in 
the question. 



92 



CLINICAL DIAGNOSIS 



The functional limits of the kidney are something enormous, as 
is seen in diabetes mellitus, in which a practically normal kidney may 
eliminate 25 litres of urine, an absolutely increased amount of the 
normal solids, and several hundred grammes of an abnormal solid, 
sugar, and stand this increased work for some time without any sign 
of disease. Kiilz was able in a rabbit by intravenous injection of salt 
solution to increase the urine to 256 cc. per hour for nine hours, and 
yet the qualitative composition of the urine remained normal. In- 
sensible and especially copious perspiration affects the amount of 
urine, which is therefore greater in cool weather than in hot. The 
latter, however, can be really no great factor, since then a person 
drinks more. It is also affected by the amount of fluid lost in other 
ways, particularly by diarrhoea and by vomiting. 

Exudates (pleural or ascitic), oedema, and other abnormal accu- 
mulations of fluid in the body are excreted through the urine. This 
explains the polyuria in nephritis as the oedema disappears. It is 
beautifully seen if the person be put on constant fluid and the urine 
carefully measured ; yet here also the excretion is not immediate, and 
may be distributed over so long a time that the demonstration fails. 

The relative amount of urine voided during the day and night has 
not received the attention which it deserves. Quincke was first to 
call attention to this point. He and his students found that in liver, 
kidney, and heart diseases producing oedema the urine voided per hour 
during the night is greater in amount and contained more solids than 
during the day, a condition sometimes called nycturia. Normally 
the reverse is true, the kidneys seem to sleep with the rest of the body, 
and the amount per hour during the day is to the amount voided 
per hour during sleep as 100: 50 to 60 or perhaps 80 to 90. The 
reverse is true in cases of cardiac or arterial disease and in nephritis, 
in which cases it would seem as if the kidney during the sleeping hours 
improved its opportunity to eliminate that which it could not during 
the day. In a well-marked case of nephritis, D : N : : 100 : 200, but 
in one case which we followed the ratio was even ioo^zj.. 1 This 
does not depend, we are convinced, upon the mere position of the 
patient and the circulatory changes dependent upon this. This has 
some diagnostic importance to differentiate those cases of functional 
(e.g., hysterical) from organic disturbances. The disturbed ratio is 
particularly marked in case the output be increased, as in diabetes, or 
by diuretics or by exercise during the day. It is not found in heart 
disease providing the compensation be good. Cardiac insufficiency 
seems the underlying cause in all cases. 2 

By polyuria is meant an increased output of urine, 3000 cc. being 

1 Johns Hopkins Hosp. Rep., vol. x. p. 323. 

2 See Laspeyres, Deut. Arch. f. klin. Med., August 16, 1900. 



THE UKINE: AMOUNT 93 

roughly considered as the upper physiological limit. If the output be 
below 800 cc. the term o 1 i g u r i a is used. The observation of one 
day is never sufficient; the increase or the diminution must extend 
over several consecutive days. These limits are very elastic, the con- 
trolling factor being the amount of fluids ingested, and the question 
always arising, is the polydipsia primary or secondary to the polyuria ? 
For instance, in the cases of typhoid fever without any apparent renal 
disturbance Dr. Cole has been in the habit this year of increasing the 
diuresis as much as possible in hopes of increasing the elimination of 
the toxines, and outputs of from 6 to 14 litres a day were not rare. 
Here the polyuria was secondary to the consumption of larger amounts 
of water than the patients desired. In other cases also of typhoid fever 
after convalescence the output of urine is increased perhaps from the 
elimination of certain solids, and the increased intake of fluids is sec- 
ondary to the tissue-thirst intensified by the depletion of water. 

Pathological factors influencing the amount of urine 
are : 

( 1 ) The condition of the renal parenchyma ; a bilateral diffuse 
lesion is usually necessary. The general law is that the more acute 
the nephritis the less the amount of urine, the more chronic the 
nephritis the greater the amount of urine excreted. In acute nephritis 
there may at first be anuria, or 50 to 100 cc. only, in a subacute 
nephritis about a normal amount, while in a chronic interstitial from 6 
to even 12 litres in twenty-four hours. In the chronic cases the reason 
for the polyuria is uncertain. It cannot be blood-pressure alone. 

(2) The velocity of the blood current through the kidney is of 
particular importance, the general law being that the amount of urine 
varies directly as the rapidity of blood-flow, not blood-pressure alone ; 
that is, as the amount of blood passing through the kidney in a unit of 
time. Hence all cases of chronic passive congestion of the renal cir- 
culation due to whatever cause have a diminished output, and drugs 
which improve this circulation are called " diuretics." This is im- 
portant in diagnosis and in prognosis. 

(3) Disturbed metabolism. The output of urine depends much 
on the quality and the quantity of the substances excreted. The best 
illustration of this is diabetes mellitus, in which disease, because of the 
sugar elimination, even 25 litres of urine may be voided, and when, 
by modifying the diet, the sugar is much diminished, the water output 
diminishes as well. Similar may be the explanation of the so-called 
" epicritical polyuria." Some cases of typhoid fever, for instance 
when convalescence begins, void from 4 to 6 litres of urine per day; 
and in almost any disease causing diminished output, as the case im- 
proves the urine is much increased. This is beautifully seen in cases 
of nephritis, especially the chronic parenchymatous. The increased 



94 



CLINICAL DIAGNOSIS 



water output following fevers may, as here, be due to the elimination 
of known or unknown bodies which were retained during the fever. 
This increased flow is a sign of favorable prognosis. 

(4) Psychical disturbances and various nervous storms may be 
followed by polyuria ; angina pectoris, hysteria, and after epileptic con- 
vulsions. The cause is probably a vasomotor one. The so-called 
" paroxysmal polyuria" is probably such a functional disturbance. 
Another cause of periodic polyuria is the periodic hydronephrosis seen 
in movable kidney, etc. 

(5) There are certain other cases of polyuria the cause of which 
is unknown. The best illustration is diabetes insipidus, in which the 
output may be as high as twelve or more litres in a day. Meyer, 3 whose 
paper is a very interesting one, considers that the trouble in this dis- 
ease is the inability on the part of the kidney to secrete a urine of 
normal concentration ; hence the person must excrete large amounts 
of water to excrete the normal amount of solids. 

In certain diseases the sequence is perhaps the following : The renal cells 
eliminate a greater percentage of the water of the blood than normal, due either to 
diseased condition of these cells, to circulatory disturbances, or to the increased 
output of some solid. This concentration of the plasma leads to a somatic thirst, 
hence the ingestion of an increased amount of fluid which is at once excreted. 
On the other hand, in the case of acute nephritis an oliguria may be due to the 
functional insufficiency of the cells to excrete water and salts. In other cases, e.g., 
subacute nephritis, there is certainly retention of salts, and the water is retained 
as a result. When these salts are eliminated the water is eliminated with them. 
It is possible that in other cases the increased amount of water voided is the 
expression of an increased output of some unknown body. 

It is often of interest to note what proportion of water intake is excreted 
through the kidneys. For normal persons 60 to 70 per cent, may be considered 
the usual limits, although the factors influencing it are many. If the water 
consumed be very much increased, the bulk appears in the urine and the per- 
centage rises to even 96 per cent, (a case of typhoid fever, with ingestion of 6772 cc. 
of fluid). In two cases of chronic interstitial nephritis the relative output through 
the kidneys was high even when this output was small ; one case with an intake of 
i960 cc, 85 per cent. ; the next day, of the 2400 cc. consumed, 86 per cent, was 
excreted by the kidneys. In another case, of 1370 cc, 85 per cent., and of 1790 cc. 
83 per cent, were thus eliminated. In chronic parenchymatous nephritis, with the 
patient in almost stable condition and receiving exactly the same amount of fluid 
each day for 26 days (6200 cc. total), the average output was 66 per cent. With 
ascites and other signs of renal insufficiency it will drop to 40 per cent, or lower, 
even in anuria to o. The following figures from a recent case of eclampsia in the 
obstetrical ward will illustrate this well. The patient was not urged to drink 
much. On the first day after the convulsions, of 8350 cc. of water drunk, the 
kidneys excreted 20 per cent. ; the next day, of 10,535 cc, 80 per cent. ; on the 
fourth day, of 9400 cc, 93 per cent. : and on the fifth the 7390 cc. of urine exceeded 
the intake of 7100 cc. During this time there was also some diarrhoea. 

Careful observations were made on but few cases, hence the above figures are 
merely suggestive. 

Anuria may be due to a variety of causes, which may be grouped 
as obstructive, reflex, renal, and prerenal. It may be simply a nervous 
3 Deut. Arch. f. klin. Med., 1905, Bd. lxxxii. 



THE MINE: SPECIFIC GEAVJTV 



symptom, seen in hysteria, in which case it is followed by a polyuria. 
It may be due to trauma, to the occlusion of the urinary passages, as, 
for instance, by stones, or a stone on one side and reflex anuria on the 
other, or to the reflex influence of nephrectomy on one side ; or to the 
condition of the renal epithelium as in acute nephritis, tuberculosis, 
cystic disease, etc. There are many so-called " pre-renal " causes of 
anuria. Among these are: certain fevers, as scarlet fever; certain 
poisons, as phosphorus, lead, turpentine, ether, and chloroform; col- 
lapse; and often, but not always, approaching death. 4 In cholera the 
anuria is attributed to inspissation of the blood. Moxon reported a 
case of ureteral calculus with anuria lasting fourteen days, and 
recovery after the passage of the stone. Adams's patient had anuria 
for nineteen days and yet recovered. Polk's patient lived for eleven 
days after his one and only kidney was removed. 

Specific Gravity. — By specific gravity of the urine is meant its 
weight compared with that of an equal volume of water. The latter 
is usually expressed as iooo. This may be determined accurately by 
weighing in a pycnometer, but clinically it is determined by a form of 
aerometer called a urometer. These spindles are usually graduated 
from iooo to 1050. It is better to use two, one graduated from 1000 
to 1020, the other from 1020 to 1040. The practitioner should get 
good instruments, as some on the market are inaccurate, especially 
those designed for use with a small volume of urine. The specific 
gravity of the urine can be put to good use, and the best instrument 
is none too good. The urine glass used should be a cylinder with 
parallel sides, wide base, and a good spout. The fluted side of the 
Squibb's model is an advantage. This glass is filled about four- 
fifths full of urine in such a way as to avoid foam, which, if present 
may be removed with a piece of filter paper. The bobbin is then 
dropped in. The observer now assures himself that it neither rests 
upon the bottom nor touches the side of the glass. If it does touch the 
side it will register from 1 to 2 points higher than it should. The read- 
ing is made with the eye on a level of the base of the meniscus. Two 
or three readings should be made, the bobbin being pushed down and 
allowed to come to rest each time. There is one point of considerable 
importance, and that is that these instruments are standardized at a 
certain temperature, usually at 15 0 C, and a difference in tem- 
perature of 3 0 means a difference of 1 in the fourth place of the 
specific gravity reading. Hence a urine which at 15 0 C. has a 
specific gravity of 1012, at 18 0 C. will read 1011. This is, of 
course, usually of slight importance with urines of ordinary concen- 
tration, yet we suspect that it explains the phenomenally low specific 
gravity in certain cases of diabetes insipidus and chronic interstitial 

4 See, also, Bevan, Am. Surg., April, 1903. 



96 



CLLNTCAL DIAGNOSIS 



nephritis. This correction is, of course, indispensable if the specific 
gravity is to be used in quantitative work, as, for instance, the esti- 
mation of the total solids or the amount of sugar or of albumin. It 
is only just to say that for the latter we think the aerometrical method 
at its best is hardly accurate enough, and the urine should if pos- 
sible be weighed on a good chemical balance. Again, an instru- 
ment suited for salt solutions is not always accurate in a sugar or 
albumin solution. 

The twenty-four hours' specimen should be examined ; this only 
has very much value, for the various portions during the day and night 
may vary from 1002 to 1040, depending on the food, the fluid, the 
lungs, the skin, etc. It may be very high after severe exercise with 
sweating, after transudate formation, etc. Two cases recently were 
refused on first examination by life insurance companies because they 
happened to have eaten some food just before examination which for 
them was a diuretic, hence an abnormally low specific gravity was 
found — in one case as low as 1003. 

The normal specific gravity is from 1015 to 1020. In the new- 
born, 1005 to 1007. 

In case there is too small an amount to fill the tube, it may be diluted to a 
known volume, the formula for the correction being : Sp. gr. — 1000 -f- ab, in 
which " b" = dilution, and " a" = the last two figures of the specific gravity found. 
For instance, if the urine was diluted with just twice its volume of water, and if 
the reading of the diluted urine was 1006, Sp. gr. = 1000 -(-3X6= 1018. 

In some cases it is not the specific gravity of the twenty-four-hours' 
specimen which is desired. For instance, in the diagnosis of an early 
chronic diffuse nephritis the constantly low specific gravity of the 
morning urine is of value. In general, however, if one has not a total 
mixed specimen, the specific gravity would better not be determined. 
This figure is in some clinics put on the temperature chart together 
with the amount of urine, the reason being that neither figure means 
much without the other. 

The specific gravity depends chiefly on the amounts of water, urea, 
and sodium chloride present. The water will depend on the same 
factors already discussed under amount. The urea explains to a cer- 
tain degree the high specific gravity in fevers. The amount of salts 
is increased by foods, by the medicines taken, and by the absorption 
of transudates. While in general the specific gravity will vary in- 
versely as the amount, this is not strictly true, since the output of 
solids is always increased by an increased output of fluids. A noted 
exception is that of diabetes mellitus, in which with increased amount 
is also an increased specific gravity, from 1025 to 1040; and in 
nephritis with renal insufficiency, in which case with oliguria the solid 



THE URINE: COLOR 



97 



output is diminished. In nephritis a low specific gravity is rather 
suggestive of an impending uraemia. It is also seen, however, in cases 
of malnutrition in which the metabolic processes are at low ebb, as 
for instance in one of Chabrie, a girl of twenty years of age, whose 
output on one day was 750 cc. with a specific gravity of 1008. In 
diabetes insipidus the specific gravity is very low. We doubt, how- 
ever, some very low figures given, suspecting that the temperature has 
something to do with one or two points. With normal amounts of 
urine there is a rather high specific gravity after operations, in rheu- 
matism, and in rickets. Ether anaesthesia diminishes the specific 
gravity, the amount remaining about normal (Brown). 

To determine the amount of solids in the urine an approximate 
estimation may be made by the use of Haser's coefficient, 2.33. The 
last two figures of the specific gravity multiplied by this empirical 
coefficient will give a clinically accurate estimation of the number of 
grammes per litre of solids excreted. 

It is surprising how much use may be made of the simple deter- 
mination of the specific gravity in quantitative work; e.g., sugar, 
albumin, etc. To have much meaning, however, the variation should 
be present on several successive days, since the physiological variations 
are considerable. 

Others disagree concerning this coefficient. Neubauer gives 2.328 ; Donze 5 
states that the coefficient should be slightly lower for dilute than for more concen- 
trated urines, varying from 1.850 to 2.440, with an average of 2.210. 

Color — The color of normal urine is usually a shade of yellow. 
This varies with the dilution of the urine, and hence directly with 
the specific gravity, being pale in the dilute and dark in the scanty 
urine. Exceptions to this are diabetes mellitus, in which case it is 
very pale and yet the urine large in amount and of a high specific 
gravity, a point which will sometimes suggest the condition; in 
anaemia, especially chlorosis, in which case the urine is pale from 
lack of pigment, since the haemoglobin is the chief source of the 
urinary pigments, but not in those anaemias in which there is rapid de- 
struction of the reds, as in pernicious anaemia ; here the urine is highly 
colored. In general, acid urine is more highly colored than alkaline. 
In uraemia it may be so pale that formerly it was thought the pigment 
retained because of renal insufficiency was the toxin causing the con- 
dition. In certain grave infections destroying the bile-producing 
function of the liver the urine is said to be without pigment. A 
febrile urine is dark, since concentrated, and also from the presence 
of uroerythrin and other pigments which manifest themselves espe- 
cially after it is exposed to the air. The contrast in color between 

5 Compt.-rend. Soc. de Biol., 1903, 155, 537. 



98 



CLINICAL DIAGNOSIS 



the day and night urines is often striking, the day urine being of a 
golden-yellow, the night of a pale green color. This is due partly to 
the amount of pigment excreted, partly to the effect of sunlight on 
the specimen collected during the day. 

A color scale is very convenient to use (such may be found in 
Purdy's " Analysis of the Urine," and Neubauer and Vogel's chart is 
published large for the urine examination-room by Kreidel, of Wies- 
baden), since a variety of terms is used in describing the same 
color (yellow, light yellow, amber, straw, etc.) With this scale should 
be compared urine in vessels of a certain depth, and against a white 
background. 

The pigments normally present in the urine are : 

Urochrome which is the one chiefly responsible for the normal 
yellow color. This is the predominant pigment of the urine, giving 
colors varying from yellow, orange, to brown, according to the amount 
present. It has not yet been isolated, its empirical formula is not 
yet known, and there may be several pigments included under this 
name. It has no absorption spectrum, no fluorescence. There is 
evidence that it is derived from urobilin. 

LLematoporphyrin is in small amounts normal in the urine (see 
pages 100 and 246). 

Uroerythrin is normal in certain cases. It explains the salmon- 
red color of the urate sediments. It is increased by a rich meat diet, 
profuse sweating, alcoholic drinks, violent exercise, and by certain 
digestive disturbances ; also in fever, circulatory disturbances of the 
liver, and rheumatism. It may be demonstrated by shaking the urine 
out gently with amyl alcohol, which will take an orange color and give 
the characteristic spectrum. This pigment bleaches in a characteristic 
manner on exposure to light. With concentrated sulphuric acid its 
solutions are carmine-red, which on the addition of an alkali changes 
from purple, to blue, to green. 

Urobilin is normally present, from 30 to 120 mg. per day. The 
pigment is itself not at first present, but a chromogen, urobilinogen, 
which on exposure to sunlight gives urobilin. Whether there are 
several urobilins, as some think, or not, is a matter of considerable 
dispute. It is so hard to isolate this body without a certain amount 
of decomposition, and so hard to exclude impurities, that the ques- 
tion is still unsettled. Its origin also is a matter of some dispute. 
One thing is quite definite, — that a certain amount is formed in the 
intestine as the result of the reducing action of certain bacteria on 
the bile pigments, enterogenous formation. It is the same as ster- 
cobilin, which certainly is derived from bile pigments in this way. It 
is not the same as hydrobilirubin. In favor of this origin is its absence 
in the urine of the new-born, after complete bile obstruction, and its 



THE URINE: C0LOK 99 

increase in intestinal decomposition. It may, however, arise else- 
where, since it is increased in cases with blood extravasation into the 
tissues (histogenous) , and in disease with increased blood destruction, 
as also after blood poisons such as antifebrin and antipyrin (hcBma- 
togenous). It is increased after a biliary obstruction is relieved. It 
is increased in fevers, chronic passive congestion, lead-poisoning, 
atrophic cirrhosis of the liver, and especially in conditions accom- 
panied by urobilin jaundice, which list includes many of the above, 
and in any disease producing jaundice excepting the catarrhal. 
Another view is that of Gilbert and Herscher and others, 6 who con- 
sider that the kidney reduces the bilirubin to urobilin, since the latter 
is a more easily diffusible' pigment. They point out that even when 
abundant in the urine none can be demonstrated in the blood unless 
much bile also be present ; that in a light case of cholaemia there will 
be no bile in the urine, only urobilin ; in the moderate cases both 
may be present, while in the severe cases in which the exhausted 
kidneys seem to give up their task of transforming this pigment only 
bile is present. Meinel 7 finds in a very few cases urobilin formed in 
the stomach in cases of hyperacidity, although this may be of entero- 
genous origin (Braunstein) . The French writers especially empha- 
size urobilin as an index of the condition of the liver, its presence 
indicating functional hepatic insufficiency, and consider an abundant 
increase a faithful sign of traumatic lesions of the liver. 8 And lastly 
is the view that if there be no liver disease and the kidneys normal, uro- 
bilinuria always means autohsemolysis. 9 

Urobilin does not give the Gmelin test. It does give a test similar 
to the biuret. If to the urine made strongly alkaline with ammonia 
and filtered be added a I per cent, alcoholic solution of zinc chloride, 
there will be seen a beautiful green fluorescence, and the absorption 
bands of alkaline urobilin may be found. This spectrum is char- 
acteristic. That of acid urobilin may be determined in a urine 
directly if a few drops of a mineral acid be added, but it is better to 
shake out with amyl alcohol and examine the extract. Or to the 
urine may be added an equal amount of 10 per cent. ZnAc in absolute 
alcohol, and the mixture filtered. 10 This test is given even in the 
presence of considerable bilirubin. The fluorescence is best seen 
with a convex lens, which gives a luminous green circle. 

For quantitative work, Hoppe-Seyler's method is recommended. One hundred 
cc. of urine are acidulated with sulphuric acid, saturated with ammonium sulphate, 

8 Compt.-rend. Soc. de Biol., 54, P- 795- 

7 Centralbl. f. inn. Med., 1903, vol. xxiv. p. 321. 

8 See also Rolleston's case of urobilin jaundice following trional in a case with 
nutmeg liver, Brit. Med. Jour., 1897, i- P- 7*9- 

•Erben, Prag. med. Wochenschr., 1904. 

10 Schlesinger, Deutsch. med. Wochenschr., 1903, No. 32, p. 561. 



100 

I 



CLINICAL DIAGNOSIS 



and allowed to stand for some time; then filtered, and the precipitate washed with 
saturated ammonium sulphate. The precipitate is then pressed out between 
blotting-paper, extracted with equal parts of alcohol and chloroform repeatedly. 
The extract is then filtered into a separating funnel, and to the filtrate is added 
two volumes of water and then chloroform until the chloroform settles out well 
in a clear layer. The chloroform solution is evaporated on a water-bath and the 
residue dried at ioo° C. It is then extracted with ether, the ether extract filtered 
off, the residue dissolved on the paper in alcohol, again brought into the weighed 
beaker, evaporated, dried, and weighed. 

The spectrophotometric method of Friedrich Miiller may be used. 

Among other chromogens in the urine are indoxyl-sulphuric acid, 
indoxyl-glycuronic acid, perhaps skatoxyl-sulphuric and skatoxyl-glycu- 
ronic acid. Pathologically, among the pigments present may be haemo- 
globin, methaemoglobin, haematin, bile pigments, melanin, and others; 
from drugs, chrysophanic acid et al. ; from the foods, the pigments 
of various berries, cherries, etc. 

Blood. — The color of the urine when blood is present depends 
upon the amount and form of the blood pigment, haemoglobin giving 
in general a reddish tint, and methaemoglobin a brownish one. The 
urine may therefore grossly be of a reddish-brown, brown, almost 
black, or greenish-black, as in the black-water fever of haemoglobinuria. 
When little is present it often has a characteristic smoky tint of methae- 
moglobin, which should always suggest blood. The urine is cloudy 
because of the large number of corpuscles and other organized ele- 
ments of sediment usually present. In the heavy sediment are masses 
of amorphous haemoglobin. 

H^matoporphyrin. — This is present in large amounts after the 
long use of trional, sulphonal, tetronal ; also in cases of typhoid fever 
and other diseases. Thick layers of the urine have a dark or a blackish 
color; thin layers a yellowish-red or violet. The black color Garrod 
thinks due only partly to this pigment, and more to an unstable purple 
one. 

Bile. — When the patient is jaundiced the urine usually contains 
bile, but in cases of very mild jaundice urobilin alone may be present. 
If bilirubin and biliverdin are present, the color of the urine will often 
be dark yellow, brown, green, or even greenish-black or quite black 
if considerable biliverdin is present together with bilirubin and other 
bile pigments, especially in long-standing cases (Garrod). If it 
stands a long time in the cold there may be a sediment of bilirubin in 
needle crystals, especially if the urine is very acid. It is often pos- 
sible to detect the presence of bile in small amounts by producing a 
foam by shaking the urine. This foam, always white in other urines 
no matter how dark they may be, is stained yellow by bile ; it is also 
yellow in case very much urobilin is present. 

Melanin. — This rare pigment is present in cases of melanotic 
tumors which have invaded the viscera. Garrod finds the amount 



THE UELNE : COLOR 



101 



of melanin to depend upon the involvement of the liver especially. 
The urine is usually of a perfectly normal color when voided, since 
the pigment is present as a chromogen, melanogen, which later splits 
giving melanin. But it may be black when voided. This transforma- 
tion may be hastened by the addition of nitric acid or other oxidizing 
bodies to the urine. It begins at the top and extends downward form- 
ing sometimes very strikingly a sharply defined layer above the color- 
less urine. Ferric chloride causes immediate blackening and a gray 
precipitate soluble in excess. Unless this reaction is positive, melanin 
cannot be assumed present. This is the most delicate and reliable test, 
(v. Jaksch.) 

Homogentisinic acid, the chief coloring body of alkaptonuria, 
gives the urine a brownish-black color and a syrupy consistency after 
standing or after the addition of an alkali (see page 207). 

The urine is sometimes very dark in peritonitis, gangrene, and 
other conditions with the formation of aromatic products of decom- 
position, the ethereal sulphates of indoxyl, etc. In these cases the 
blue color sometimes seen is not indigo, but a higher oxidation 
product of indol. Such urines blacken on the addition of nitric acid, 
if warmed, but not if cold. They do not blacken with ferric chloride, 
and do not reduce copper solutions. In one striking case in our wards 
the fresh urine of a woman who had been markedly constipated was 
of a very dark greenish-black color, but after the bowels had moved 
well the next voiding was of practically normal color. Some indican 
was present, but not nearly enough to explain the color. 

In some cases the urine is very dark on voiding; in others after 
long standing. This may be due to pyrocaiechin, C 6 H 4 (OH) 2 (i, 
2) , which in watery alkaline solution is oxidized by the air and becomes 
a greenish-brown and finally a black color. The urine containing it 
becomes therefore dark, reduces alkaline copper sulphate in warm 
solution, but not bismuth. Another view (Baumann) is that pyroca- 
techin is derived from the vegetables of the food. 

To isolate, the urine is concentrated, filtered, a little sulphuric acid added, and 
then boiled to drive off the phenol. It is then shaken out repeatedly with ether; 
the ether is distilled off, the residue neutralized with barium carbonate, and shaken 
out again with ether. The ether is then evaporated off and the pyrocatechin 
allowed to crystallize out. 

Hydrochinon, C 6 H 4 (OH) 2 (i, 4), occurs after the use of phenol. 
Its decomposition product gives a dark color to the urine and reduces 
copper easily. 

Urine containing the alkapton bodies and indican is clear on void- 
ing, but soon becomes dark. In the latter case the blue of the indigo 
may not be pronounced, as it is modified by the yellow of the urine. 
The scum, however, may be blue. Sahli mentions the case of a boy 



102 



CLINICAL DIAGNOSIS 



in which the urine when voided was of a green-grass color due to 
the combination of the indigo with the yellow of the urine. 

Ochronosis is a rare disease with blackening of the cartilages. The 
urine of these patients turns black on standing. Osier reported two 
cases of ochronosis with alkaptonuria, but in other cases it is said that 
the black color of the urine was not due to alkaptonuria. 

In certain cases the urine on voiding is black. In others it is first 
colorless but soon turns black. The pigments in these cases have not 
been determined, but all the above mentioned causes it is said are 
excluded. 

Garrod 11 classifies the black urines as, those due to long-standing 
jaundice; certain cases of hematuria, hemoglobinuria; melanotic sar- 
coma ; alkaptonuria, ochronosis ; great abundance of indoxyl-sulphate ; 
certain cases of tuberculosis after standing for some time, a month 
even (the cause not known); perhaps phenol derivatives, certain 
drugs as phenol ; and rare cases due to an unknown pigment. Those 
truly black are only melaturia, and alkaptonuria on standing. 

In chyluria the urine is of milky appearance. 

Colors due to Medicines. — The list of medicines which may 
affect the color of the urine is too long to tabulate. In general, 
it may be said that in case the urine presents any unusual color, 
inquiry should always be made concerning the previous medication. 
Among these drugs particularly are carbolic acid, whether applied 
internally or externally, tar preparations, resorcin, naphthol, salol, arid 
many aromatic bodies. The color in these cases often appears only 
after long standing, and especially when the urine is alkaline, and 
when hydrochinon and pyrocatechin are formed. Methylene blue, 
even in small amounts, o. i gm., will color the urine for several days. 
Hence the result was startling in cases of -malaria treated with large 
doses of this drug. In one hour after the dose the urine has a greenish 
color, later a deeper green, then a blue, which may last three to four 
days. The color may be intermittent, present only in the first morning 
voiding. It may be intensified or produced by boiling the acid urine, 
adding acetic acid if necessary, since the pigment is partly reduced in 
the body to a colorless form. W eber 1 2 thinks methylene blue explains 
practically all the blue and green urines, and doubts cases ascribed to 
indigo blue. He emphasizes the common use of this dye to color 
candies and food-stuffs. 

Some colors are of clinical importance only incase of a drug applied 
externally and hence in uncontrollable doses. What the factor is 
which changes the color of the urine cannot always be determined; 
for instance, after a small dose of salol the urine may be of a very 

11 The Practitioner, 1904, vol. lxxii. p. 383. 
"Lancet, September 21, 1901. 



THE TJKIKE: BEACTION 



103 



dark color, while after much larger doses there will be no change. 
Whether this is due to the acidity or to the time of exposure to the 
air cannot be said. 

After drugs containing chrysophanic acid, as, for instance, chry- 
sarobin, rhubarb, santonin, senna, and others, the urine is of a yellow 
tint when acid and red when alkaline. The pigment of many vege- 
tables will change the color of the urine. Among these may be men- 
tioned turnips, whortleberries, blackberries, and others. 

Odor. — The odor of the normal fresh urine is not unpleasant. The 
so-called urinary odor is due to the ammoniacal decomposition by the 
bacteria. In a decomposing albuminous urine the odor is especially 
disagreeable, and a diagnosis of albuminuria may be made from that 
alone. There is said to be an intolerable odor in cases of cancer of 
the bladder and deep inflammatory disease of the urinary tract. Cha- 
brie believes in a characteristic odor in certain cases of abnormal 
metabolism with incomplete combustion, such as is present in diabetics 
and oxalurics. We may even suppose that he thinks that one of the 
great masters of French medicine could diagnose insanity from the 
odor of the urine alone. There is said to be a special odor in chyluria 
and even in slight hematuria. Other cases have a remarkable absence 
of odor. It should always be remembered, however, that the bottle in 
which the patient brings the specimen may explain the odor. We 
have noticed a strong odor of H 2 S in certain nephritics, even when 
the urine was quite fresh. 

Certain substances are excreted as such in the urine. Among 
such are valerian, asafetida, coffee, and various foods. Others build 
odorous bodies. Among these are the balsams, copaiba, cubebs, etc. 
After the administration of turpentine the odor of the urine is that 
of violets. After eating asparagus there is a characteristic odor 
attributed to methyl-mercaptan. 

General Appearance. — When fresh the urine is clear. If there is 
then any distinct cloudiness, it is due to an abundant organized sedi- 
ment or to a precipitation of phosphate seen in the so-called phos- 
phaturia and in ammoniacal cystitis. Very soon a faint nubecula ap- 
pears in the upper layers of a clear urine, which consists of mucous 
strands enclosing a few cells. After standing, the urine will become 
cloudy, either from a urate sediment, which before settling may give 
a uniform milky appearance, or particularly during the summer 
months to the rapid growth of bacteria and the precipitation of the 
phosphates in the alkaline urine. 

Reaction. — Concerning the reaction of the urine there has been 
much work done in regard to the value of which much difference 
of opinion exists. All admit that its determination would be valuable 
could satisfactory methods be found. 



104/ 



CLINICAL DIAGNOSIS 



Until recently by " degree of acidity" was understood the amount 
of hydrogen which could be replaced by the metal of an alkaline solu- 
tion (NaOH), regardless whether these hydrogen ions were already 
dissociated or could be substituted by the alkali. Now is meant the 
absolute number of dissociated H-ions per one litre of urine. The 
latter contribution of the physical chemists is interesting, indeed, but 
of little value to the clinician. Judged by this, urine is only about 
thirty times as acid as distilled water, and only about one ten-thou- 
sandth as acid as titration would indicate, and the difficulties of its 
determination rule this out from clinical methods. The titration 
method alone is possible for general use, and the question arises if its 
results are of any real value or simply of an empirical arbitrary value. 
Hober 13 claims, as the result of parallel estimations, that these two 
" acidities" vary sometimes, often perhaps, in a very independent 
manner, hence variations in each would have different values, and 
neither method would be able to replace the other. The question, 
therefore, is, Does the titration method give results valuable enough 
to repay the time, or are the results worse than useless since mislead- 
ing? The difficulties are that the acidity of the urine in the common 
sense of the term depends upon a considerable number of chemical 
substances, for the most part acid salts, and hence the question of 
color indicator is a very serious one, since the points indicated by the 
various ones as the neutral point differ and none is by any means the 
theoretical one. Phenolphthalein is the one usually used. This has as 
practical advantages the sharpness of its end reaction and the fact 
that of the indicators it is itself the weakest acid. But it is a poor 
indicator in the presence of ammonium salts, perhaps the worst. 
Whatever results are obtained with it must be given not an absolute 
but an empirical value. Yet the opinion of those working in this line 
is that the results with it are comparable. 

The reaction of the twenty-four-hour amount of well-preserved 
urine is, in the case of man, always faintly acid to litmus, a degree 
corresponding to about 1.15 to 2.3 grammes of HQ for twenty-four 
hours. This acidity depends chiefly upon the diet, and is greater the 
more the proteid oxidized. The urine of herbivorous animals is 
alkaline, since the organic acids of their food are oxidized to alkaline 
carbonates, yet if starved, acid, since then their tissue proteid is their 
diet. A man on a vegetable diet will have a less acid, or amphoteric 
urine perhaps, from this increased ingestion of alkali-forming foods. 
In no case is there free acid in the urine, the acidity being due to acid 
salts, and particularly diacid sodium phosphate. There are many other 
acids produced in the oxidation of proteids themselves neutral. 
Among these are sulphuric, phosphoric, uric, hippuric, oxalic, and the 

13 Hofmeister's Eeitr., 1903, vol. iii. p. 525. 



THE URINE: REACTION 



oxyaromatic acids, Just what part these play, however, cannot be 
decided, but certainly uric acid is no factor, since its solution is neutral 
to litmus. 

A constant acidity is found only after and during starvation. 

Variations in the reaction are due to the diet, as mentioned above. 
The acidity is highest in the morning before breakfast and lower a 
few hours after each meal, and especially in the forenoon, due to the 
secretion of hydrochloric acid of the gastric juice. For a short time, 
from two to four hours, after a meal the urine may be alkaline when 
freshly voided and turbid with sediment of the phosphates of the 
alkaline earths. This condition is known as " phosphaturia." Nor- 
mally this diminished acidity of the urine, known as the " alkaline 
tide," disappears after a meal, since then the hydrochloric acid is 
reabsorbed. 

Phosphaturia is the term given to a symptom-complex with a 
heavy precipitate of the earthy phosphates in the freshly voided urine, 
yet without the formed elements which would indicate a lesion of the 
tract. It was supposed to be due to an increased output of phosphoric 
acid. Chemically, however, there is no such increase, but often a 
decrease, and so the name " alkalinuria " is more suitable. Phos- 
phaturia occurs when the diet raises the alkalinity of the blood, as 
will a vegetable one; in gastric diseases with considerable loss of 
hydrochloric acid to the body through hypersecretion with motor 
insufficiency and vomiting or lavage, perhaps diarrhoea also; and 
especially as a symptom of neurasthenia (Peyer ) without any of the 
above-mentioned' causes. In such a case during the periods of neuras- 
thenia has been found a diminution in the phosphoric acid to about 
half, but an increased calcium output. The nitrogen was also de- 
creased. It seems to be the excess of calcium relative to the phosphoric 
acid which leads to the precipitation. In Soetbeer and Krieger's 
case the phosphoric acid was practically normal, the calcium increased 
even to 0.7 gm. a day (normal 0.2) and Ca : P 2 0 5 : : 1 : 1.5 to 2 
(normally 1: 12). In certain cases 14 there seem to be during the 
period of phosphaturia symptoms referable to this abnormal metabo- 
lism and which disappear with it. They seem, however, to be due 
to changes in calcium metabolism rather than to those in that of 
phosphoric acid. In one case the calcium was increased over three 
times, perhaps the result of catarrh of the colon. It occurs also in 
persons after sexual excesses, and in the depression following psychical 
exaltation, in which cases the cause is not known, but a nervous control 
is suspected. Freudenberg 15 carries this idea to extremes, separating 

11 Soetbeer and Krieger, Deut. Arch. f. klin. Med., 1902, vol. lxxii. p. 553 ; 
Patek, M. J., vol. xxx. 

15 Detitsch. med. Wochenschr., September 17, 1903. 



106/ 



CLINICAL DIAGNOSIS 



phosphaturia, latent phosphaturia ( in which the precipitate appears on 
heating the fresh urine), and ammonuria (tested by moist litmus over 
the month of a tube of heated urine), three grades, he thinks, of the 
same abnormality, which he found in sexual neurasthenics especially, 
but not in patients with hysteria. It is often found among mental 
cases (Heinicke). Some few cases with general symptoms have 
really increased phosphoric acid as their only objective sign; later, 
perhaps, polyuria or glycosuria. Senator suggests that some cases 
of diabetes insipidus with rather high specific gravity may belong here. 

The reaction of the urine can be much modified, even made alka- 
line, by drugs, particularly by alkaline salts in large doses. Milk of 
lime will give an alkaline urine due to the presence of ammonium 
carbamate (Abel). While a transudate is quickly absorbed the urine 
may become alkaline : also after hemorrhage into the intestine, in which 
case the blood salts are absorbed. It is alkaline in certain cases of 
pneumonia, typhoid fever, and diseases of the central nervous system. 
We have noted a marked alkalinity in certain cases of nephritis, 
particularly of the severe chronic parenchymatous form with much 
oedema, which renders the examination of casts difficult. The urine 
is also alkaline when there are alkaline secretions and exudates of the 
urinary tract, as in cases of cystitis or urethritis ; and lastly in alkaline 
fermentation in the bladder. 

The alkalinity is, of course, usually due to the changes occurring 
after the urine is voided. Bacteria begin at once to break the urea 
up into ammonium carbamate and carbonate. 

It is of importance to determine whether the alkalinity is due to 
a fixed alkali or to ammonia. If to the latter, it is always the result of 
bacterial fermentation. Which it is may be determined by wetting 
red litmus paper in the urine and then drying it ; if the alkalinity is 
due to ammonia, the red color will return when the paper dries. Or, 
moist litmus paper is hung in the mouth of the bottle. It will, if much 
ammonia be present, turn blue. But even normal urine contains a 
certain amount of ammonia, and hence the paper if left long enough 
will usually turn slightly blue. 

The acidity of the urine can with difficulty be increased, and not 
beyond a certain point. This occurs with increased proteid metabo- 
lism. Cases of hyperacidity, even two to five times normal (phenol- 
phthalein as indicator), and accompanied by symptoms of cystitis, pain 
especially in the trigonal region, but without demonstrable lesions or 
assignable cause, are reported by Brown 16 in cases of girls and young 
women of distinctly neurotic temperament. He suggests that it is a 
neurosis of urinary secretion. The urine is very acid in diabetes 
mellitus if it contains considerable oxybutyric and diacetic acids. The 

18 Phila. Med. Jour.. March 2. 1901. 



THE UEIME: NITKOGEN 107 

question of the reaction in the so-called " uric acid diathesis " is not 
yet decided. The reason that it is so difficult to increase the acidity 
in the case of man is that the body will protect itself against an acid 
intoxication by an increased excretion of ammonia, thus protecting its 
native mineral alkaline store from depletion. This ability is present 
in the herbivora to a much less extent, and hence they are more easily 
poisoned by acids than is man. 

The effect of muscular work on the urine reaction is still doubtful. 

As the urine decomposes, in some cases in from six to twelve 
hours' standing, it becomes more acid, the so-called " acid fermenta- 
tion." The reason of this is uncertain. It is inconstant and is always 
soon succeeded by an alkaline decomposition. Hammarsten considers 
it due to the reaction between the biurates and MH 2 P0 4 . 

Determination of the Total Acidity of the Urine. — Naegeli 17 advised to 
add the N/io XaOH directly to 10 cc. of urine, phenolphthalein used as indicator. 
The error is at least 4 to 8 per cent. 

(For the Freund method, see page 137.) 

Folin 1S uses potassium oxalate in excess to rule out the error from ammonium 
salts and calcium phosphate. His method is as follows : 

Twenty-five cubic centimetres of urine are measured by a pipette into a 200 cc. 
Erlenmeyer flask, one or two drops of 0.5 per cent, phenolphthalein solution added, 
and 15 to 20 gms. of potassium oxalate. The flask is shaken well for one minute, 
then at once titrated with N/10 NaOH, shaking all the time. The alkali is added 
until a faint yet distinct coloration is produced. 

The Mineral Acidity of the Urine — Folin's Method. — From 0.3 to 0.6 gm. 
of pure, dry, granular potassium carbonate is accurately weighed (within an 
accuracy of 0.2 mg.) into a platinum dish, and 25 cc. of urine are measured into 
it. (If the urine contains much albumin this should be removed by acidifying with 
pure acetic acid, boiling, and filtering. A trace of albumin contains too little 
sulphur to affect the results appreciably.) The resulting alkaline solution is evapo- 
rated on the sandbath or electric oven to dryness, and when perfectly dry the 
contents of the dish are burned at just below red-heat (that is, the dish should 
never be more than faintly red-hot) over a so-called " radial burner " giving a 
flame wide enough to heat the entire bottom of the platinum dish. One must be 
sure the gas used does not contain sulphur. If there is any doubt on this point 
(which is tested by burning some of the pure potassium carbonate in the platinum 
dish and testing the contents for sulphates) an alcohol flame may be used. If the 
entire bottom of the platinum dish is not evenly heated the cyanogen derivates of 
urea, which resemble mineral matter, will melt, flow to the cooler portions, and 
escape decomposition. 

The burning should continue for about an hour after all ammoniacal fumes 
have ceased to come off. Then the flame is removed. It makes little difference 
if the ash is not perfectly white. Just 10 cc. of hydrogen peroxide water are next 
added, the dish covered with a watch glass, and gently warmed until the peroxide 
is decomposed. The watch glass is then removed and the sputterings rinsed into 
the dish bv means of a little water. The contents of the dish are again evaporated 
to perfect drvness, and are again heated over the radial burner as before for about 
an hour. The hydrogen peroxide is used to oxidize the thiocyanates and any small 
amount of sulphides which may have formed during the burning. Even with these 
precautions the complete combustion of the urine is very difficult. 

"Zeitschr. f. physiol. Chem., 1900, xxx. 313. 
18 Am. Jour. Physiol., 1903, ix. 265. 



108 



CLINICAL DIAGNOSIS 



The residue is now dissolved in water with the help of an excess of N/io HC1 
(75 or 100 cc., depending on how much carbonate was used), and is rinsed into 
an Erlenmeyer flask, boiled to drive off the carbonic acid, and cooled. The excess 
of acid is then titrated with N/10 NaOH in the presence of a small amount of 
potassium oxalate (to precipitate the calcium) and two drops of a one-half per 
cent, solution of phenolphthalein. 

Since the amount of alkali and of acid added to the urine are known, the final 
titration gives the data for calculating the apparent excess of mineral acids or 
alkalies originally present in the urine. Before the final result is obtained certain 
other factors must, however, be taken into account. One must determine: (1) the 
alkaline strength of the potassium carbonate; (2) the acidity of the hydrogen 
peroxide; (3) the S0 3 content of the hydrogen peroxide; (4) the preformed 
ammonia in the urine; (5) the inorganic S0 3 of the urine; and, finally, (6) the 
total SOs found in the titrated solution of the urine residue. 

The potassium carbonate and hydrogen peroxide will keep for months in well- 
stoppered glass bottles, so the first three determinations need be made but once 
(for any given sample of carbonate and peroxide). 

To calculate the result, one subtracts from the apparent excess of acidity found 
on titrating the burned urine residue the sum of the preformed ammonia, the 
acidity of the hydrogen peroxide and the acidity due to the organic SO3 of the 
urine, all in terms of tenth normal acid. 

The acidity (in cubic centimetres of tenth normal acid) of the organic SO3 
is obtained by subtracting the sum of the S0 3 of the hydrogen peroxide and the 
inorganic S0 3 of the urine from the total SOs of the urine residue, and dividing 
the amount thus obtained in milligrammes by eight. (Eight grammes of the 
organic sulphur, neutral and etherial, are taken to represent 1 cc. of N/10 acid.) 

To illustrate: 25 cc. of urine were burned with 0.5287 gm. of potassium 
carbonate (7.76 mg. of which contained 1 cc. N/10 alkali). The burned residue 
was boiled with 75 cc. of tenth normal HC1 and the titration required 1 cc. tenth 
normal NaOH. An ammonia determination gave 5.2 cc. N/10 NH 3 in 25 cc. of 
urine. The total S0 3 = 59.9 mg. ; the inorganic S0 3 = 42.8 mg. (10 cc. of the 
hydrogen peroxide used contained 8.8 mg. S0 3 and 0.5 cc. N/10 acid.) 



0.5287 gm. K 2 C0 3 


= 68.1+ 


cc. N/10 NaOH 


NaOH added 


= 19- 




Total alkalinity 


= 87.1+ 




HC1. added 


= 75- 




Apparent acidity of 


urine = 12. 1 


" " HC1. 


Ammonia in 25 cc. urine 


= 5-2 


< < t < < « 


Acidity of H 2 0 2 


= 0.5 


<c <( <« 


Acidity of organic S0 3 ^= 59 - 9 ~ (4 ^ 


H-8.8) _ t 


(( (I C( 




6-7 





Mineral acidity in 25 cc. = 12. 1 — 6.7 = 5.4 cc. N/10 HC1. 

The Organic Acidity in Urine. — By subtracting the mineral acidity from 
the total acidity one obtains the " organic acidity," or rather the total equivalence 
of organic acid whether free or combined. In cases of acid intoxication, as in 
diabetes, the mineral acidity may turn out to be an alkalinity and all the acidity 
be organic. In the latter case the mineral alkalinity is added to the total acidity 
to get the organic acidity. 



THE URINE: NITROGEN 



109 



THE NITROGENOUS BODIES. 
The Nitrogen Output— The total nitrogen of the urine is the 
best index of proteid metabolism. It is fortunate that for this, our 
stand-by in metabolism work, we have a satisfactory method of deter- 
mination. The same cannot be said, however, of the several nitrog- 
enous bodies. 

Folin, 19 from his careful study of the urine of normal men, 
determined that the amount of nitrogen and its distribution was, 
if the diet be nitrogen-rich, that given in Table I. The figures he 
obtained in one case on a very low nitrogen intake are given in 

TaMe 11 Table. I Table II 

Total nitrogen 14.8-18.2 gm. 4.8- 8.0 gm. 

Urea-nitrogen 86.3-89.4% 62.0-80.4% 

Ammonia-nitrogen 3.3- 5.1% 4.2-11.7% 

Creatinin-nitrogen 3.2- 4.5% 5.5-11.1% 

Uric acid-nitrogen 0.5- 1.0% 1.2- 2.4% 

Undetermined nitrogen .... 2.7- 5.3% 4.8- 14.6% 

The figures found in most text-books for total nitrogen in the 
urine of the normal adult on mixed diet are from 10 to 16 gms. per 
day. The distributions of this nitrogen in the urine of adults and 
infants are, according to Hammarsten : * 

Urea 84 -91 73 -76 

NHs . 2 - 5 7.8- 9.6 

Uric acid 1 - 3 3 - 8.5 

Extractives 7 -12 7.3-14.7 

The sum of the nitrogens of urea and ammonia bears a very 
constant relation to total N (91 to 93 per cent.), a much more constant 
one than does either alone. 19 

The most of the work done on the nitrogen of the urine is value- 
less since due attention was not paid to< the total nitrogen of the food, 
the character of the food (its acid- or alkaline-producing qualities), 
and the age, nutritional condition and previous diet of the patient. 
Again the periods of observation should be at least seven days long, 
the diet during this time should be constant, and the daily amount of 
water consumed should also be constant. The patient should exercise 
a fairly constant amount each day. But. even when all these points 
are carefully watched, marked variations in the nitrogen retention and 
elimination will be observed. 

By " nitrogen balance " is meant the relation of the nitrogen intake 
to the nitrogen output. The difference between these two figures is 
usually called the " nitrogen lost " and the " nitrogen retained." When 
the output is just equal to the intake the person is said to be in 
" nitrogenous equilibrium." 

19 Folin, Am. Jour. Insan., 1905. 

* Lehrb. d. phys. chem., 1899, p. 421. 



110 



CLINICAL DIAGNOSIS 



In general the total nitrogen is increased as a result of increased 
proteid metabolism, a heavy proteid meal, or anything increasing body 
proteid catabolism. Less is excreted on a diet rich in carbohydrates 
than even while fasting, since in the latter case the body lives on its 
tissue proteid. The output reaches its maximum a few hours after 
a heavy proteid meal. The evidence given that exercise increases the 
output is in part that the amount excreted during the day is to the 
amount excreted at night as 3 : 2. We hardly think that this alone is 
sufficient evidence, for it has been only too well shown by studies of 
the day and night urine that normally the kidneys can rest at night as 
well as the rest of the body. Hot baths increase the nitrogen output. 

With increase of water excretion that of nitrogen also is increased. 
This latter point is important, for even when the diet is fairly constant, 
if by any reason the amount of urine be increased, the nitrogen 
also will rise. One explanation given is that the renal cells are always 
stored with a certain amount of nitrogenous waste which the water 
constantly removes; others say that the many tissue ferments, follow- 
ing the general law of ferments, act better in dilute solution. 

Pathologically nitrogen is increased : in fever, owing not to the 
temperature per se, but more likely to the effect upon metabolism of the 
toxines causing the fever, — excepting acute nephritis causing dropsy 
and diseases with diarrhoea or with large exudates : in cachexia, for in 
these cases there is a rapid breaking down of tissue proteid ; in diabetes, 
since the most of these patients are on a proteid-rich diet, and the 
severe cases even if on a mixed diet burn only the protein of their 
food and tissues; after various poisons, as arsenic, antimony, 
phosphorus , and other protoplasm poisons ; and anything diminishing 
the oxygen intake, as prolonged dyspnoea, hemorrhage, carbon monox- 
ide poisoning, etc. During the resolution of a pneumonic exudate its 
digestion and excretion can be well followed by the nitrogen of the 
urine, and the amount of lung cleared estimated. In a case of 
Miiller's the excess of nitrogen output during the resolution was 28 
gins., which represented 800 gms. of exudate. The continued large 
output in cases of delayed resolution would indicate a " chronic pneu- 
monia," rather than a failure to resolve. Cook 20 reported a few such 
cases, in one of which, with one lung involved, the nitrogen output 
would represent the exudate of four solid lungs. 

In much of the work on metabolism the urea, not nitrogen, has 
been followed, and by methods which determine really more the total 
nitrogen, as, for instance, Liebig's, or those of Hiifner, et ah, which 
are quite faulty. 

By combining the findings of these two lines of work, to the 
above may be added that in general anything increasing proteid 

20 Johns Hopkins Hosp. Bull., December, 1902, p. 307. 



THE URINE: NITE0GEN 111 

catabolism increases the nitrogen. Again, anything increasing- the 
water output will increase the nitrogen, as, for instance, in diabetes 
insipidus (in which disease 130 gins, of urea have been reported) 
and cases of chronic nephritis with polyuria. Again, the nitrogen is 
increased when exudates or transudates are absorbed. 

Retention of nitrogen occurs in a person gaining weight, in myxe- 
dema, in the convalescence of fevers. In one case of convalescent 
typhoid (Liithje) the record was reached, in twenty-six days the 
person retaining 121.38 gms. of N, which would represent 758.6 gms. 
of albumin or 3568.6 gms. of muscle. The person gained 6490 gms. 
in weight. This retention of water and nitrogen is well seen in the 
last of pregnancy, and is followed by a diuresis and increased nitrogen 
output, which begins about the second clay of the puerperium and lasts 
about two weeks. 21 

The amount considered normal, 10 to 16 gms. per day, is this high 
because we eat almost twice too much. Vegetarians can accustom 
themselves to a 5 to 6 gms. output and even then store up nitrogen. 

The amount excreted is diminished physiologically by a poor diet, 
and especially by one rich in carbohydrate ; when the water is reduced 
as a result of free sweating, etc. ; in pregnancy ; and by small closes 
of quinine. Pathologically, it may be diminished by a diminished 
absorption of the proteid in the intestine; or the oxidation in the 
body may be at low ebb, as in cases of very reduced vitality, and 
at the end of acute fevers. The diminution may result from the re- 
tention of bodies which should be excreted, as in cases of dropsy, 
exudate or transudate formation, also when there is a very small 
water output ; or there may be an inability to excrete, as, for instance, 
in a severe nephritis in which the drop in urea may be one of the first 
serious symptoms heralding the onset of uraemia. This inability to 
excrete is also seen in mere functional disturbances of the kidneys; 
also before death due to any cause. In some cases it may be mani- 
fested by the urea frost, the urea crystallizing on the skin. 

Estimation of Nitrogen — The Kjeldahl method is quite uniformly 
used. Of this there are several modifications. That most commonly 
used is Gumming's. For all modifications it is necessary to have 
combustion flasks of Jena glass of about 250 to 300 cc. capacity, and 
an ordinary distilling apparatus with a good cooling jacket (see Fig. 
21, C). To the urine, in amount varying from 5 to 20 cc. according 
to its concentration, are added 15 cc. of pure concentrated sulphuric 
acid, 10 gms. of potassium sulphate, and about 1 gm. of copper sul- 
phate. This, supported on a sheet of asbestos gauze, is then boiled 
over a free flame in a hood with a good draft until the fluid is a clear 
blue. The worker should be careful, if it is necessary to wash down 

21 Siemons, Johns Hopkins Hosp. Rep., vol. xii. 1904. 



CLINICAL DIAGNOSIS 



the carbon from the sides of the glass by shaking the fluid, that he 
does not burn himself with this exceedingly hot acid. After the fluid 
is perfectly blue the heat should be continued for a few minutes or 
even half an hour, that the combustion may be perfect. Uric acid 
and other bodies are perfectly oxidized only after at least half an 
hour's further heating of the clear fluid. By this means practically 
all of the nitrogen has been converted into ammonia, and is hence 




Fig. 21. — Distilling' apparatus for nitrogen determination (Kjeldahl). A, Distillation flask; B, 
safety bulb ; C, Liebig cooler ; D, Erlenmeyer flask to receive distillate and containing the standard acid ; 
E, safety bulb to prevent back-flow. 

present as ammonium sulphate. The oxidation may be aided by 
adding a little KMn0 4 . The fluid is allowed to cool perfectly, dis- 
tilled water is then added in excess, and the fluid poured into a dis- 
tilling flask (see Fig. 21, A) of 1 litre capacity, with long neck and 
round bottom. The combustion flask is well washed into this flask, 
rinsing it three or four times with distilled water. Talcum powder 
or zinc granules may be added to prevent bumping. An amount of 



THE TOINK : UREA 



113^ 



strong sodium hydroxide, specific gravity 1230, found by previous 
experiments sufficient to more than neutralize the acid, is now added 
and the flask at once fitted to the Liebig cooler. The lower end of 
this cooler ends in a bent tube which vertically descends to the bottom 
of a small Erlenmeyer flask, D, of about 300 cc. capacity, in which 
have been put previously just 50 cc. of fourth-normal H 2 S0 4 . In 
the subsequent distillation, therefore, all the ammonia, both that given 
off at once in the cold and that on boiling, bubbles through this acid 
and is thus caught. The distillation is continued until about 100 cc. 
of distillate have passed over, but the boiling should never be too 
vigorous, and the apparatus should be watched to be sure no acid 
spurts into the cooler ; hence the vertical tube has a safety-bulb, B, to 
prevent this. The Erlenmeyer flask may then be lowered and the 
distillate tested with lacmoid paper, to make sure that the ammonia 
has entirely passed over. The acid clinging to the end of the tube is 
washed into the flask. This sulphuric acid is then titrated against 
fourth-normal NaOH, using cochineal, methyl orange or pure litmus 
as indicator. There can be no doubt that the pure litmus is the best 
if the necessary precautions are used. The most convenient is 
cochineal, which can be used in artificial light as well, and is sufficiently 
correct for ordinary work. (The cochineal bugs are ground fine 
and extracted with 50 per cent, alcohol. The filtered extract is used 
as indicator.) From the 50 cc. are subtracted the number of cubic 
centimetres of fourth-normal NaOH, and the difference indicates the 
amount of fourth-normal H 2 S0 4 neutralized by ammonia. This 
value multiplied by 0.0035 gm. would equal in grammes the weight 
of nitrogen in the amount of urine used. 

(Note. — This method does not indicate nitrates or nitrocom- 
pounds. ) 

In many laboratories the nitrogen of the urine is determined 
without distillation. The contents of the combustion flask are poured, 
and then the rinsings washed, into an ammonia-determination appa- 
ratus, the alkali added, and the determination continued as for 
ammonia (see page 123). 

For the relation between carbon and nitrogen, see Richard- 
ion. 

Urea is the chief nitrogenous body of the urine and the one which 
until recently has attracted most attention. The methods employed 
to determine it (Liebig's, Hiifner's, ei al.) have not given correct 
results. The first, in fact, gives a fair nitrogen determination, and 
the second, a result fairly correct in some, but very incorrect in other 
cases. 

23 Am. Jour. Med. Sci., 1902, vol. cxxiv. 

8 



CLINICAL DIAGNOSIS 



The amount of urea as an index of nitrogen metabolism has been used as a 
test of the digestion. In this case a meal containing an excess of nitrogen is 
given, for illustration, 500 gms. of meat, eight eggs, and 200 gms. of bread; during 
this and the following day at least 50 gms. of urea should be excreted. 

The amount of urea excreted by a normal person on an average 
diet varies from 20 to 40 gms., more in the case of men than of 
women. On a poor diet it may be from 15 to 20 gms.. while on a 
very rich diet figures as high as 100 gms. in twenty-four hours have 
been reported. In general it may be said that for a vigorous person 
on an average diet about 30 gms. may be expected ; for an invalid, 
about 20 gms. 

The urea may be diminished because the nitrogen is diminished, 
or is excreted in other forms, particularly as ammonia. One of the 
most important functions of the liver is that of changing ammonia to 
urea; hence in certain cases of liver disease the output of urea dimin- 
ishes and that of ammonia increases, constituting even 50 to 60 per 
cent, of the total nitrogen (see page 115). It is true, however, that 
in other cases with marked gross lesion of the liver the percentage 
is about normal. Again, the nitrogen may be eliminated as ammonia 
because of acids ingested or formed within the body and neutralized 
by it to protect the mineral alkali ; hence it is withdrawn from urea 
formation. Such is true in diabetes and in cachexia, in which there 
is a disturbance of the carbohydrate absorption or use, thus forcing 
the body to use only the pure proteid of food or tissues, — that is, an 
acid-producing diet. 

But the interesting question now is, Why is there any urea in the urine? 
There are various opinions on this point. One is that urea is the chief nitrogenous 
ash of nitrogenous food, and that a normal American on an " average " American 
diet will excrete from 20 to 30 gm. of it each day. Another opinion is that the 
urea represents that part of our nitrogenous intake which is over and above that 
which we really needed, and that the man " living rationally " would have very 
little urea in his urine. Another view is not so radical : It is that in protein diges- 
tion the split products are perhaps not resynthesized to protein, but the cleavage 
liberates the carbonaceous portion of the protein molecule which is used, while the 
nitrogenous portion is not used and is finally excreted as urea. One quite certain 
fact is that urea is the only nitrogenous ash which is diminished absolutely and 
relatively when the total nitrogen output is diminished, and that a man can keep 
in nitrogenous equilibrium and in good (?) health on an astonishingly limited 
diet (see the table on page 109). 

Estimation of Urea. — The Mdrner-Sjoqvist. — This method was thought reliable 
for the determination of urea alone. Albumin must first be removed by heat and 
acetic acid, and then the original volume of urine restored. Five cc. of urine are 
placed in a flask with 5 cc. of a barium mixture (saturated barium chloride solution 
to which barium hydroxide is added till 5 per cent, in amount) ; 100 cc. of a mixture 
of 97 per cent, alcohol, 2 parts, and ether, 1 part, are then added. This is allowed to 
stand until the next day in a closed vessel. It is then filtered on a suction filter, pref- 
erably through a small filter paper about 10 cm. in diameter and into a Kjeldahl flask. 
The precipitate is well washed with alcohol and ether. It is sufficient to obtain 
about 50 cc. of filtrate. Urea will be practically the only nitrogenous body left 



THE URINE: UREA 



115 



in solution. The alcohol and ether are then evaporated off at a temperature not 
above 6o° C, or distilled off at reduced pressure if a good suction pump is at 
hand. When about 25 cc. are left there is added a little water and burnt magne- 
sium oxide and the evaporation or distillation continued until the distillate is no 
longer alkaline, which is true, as a rule, when only from 10 to 15 cc. are left; 
otherwise ammonia will be left in the filtrate. The fluid is then poured— and the 
flask washed — into a flask. A few drops of concentrated sulphuric acid should 
then be added, and it is then evaporated on a water-bath to a very small volume, 
since we wish to get rid of all the alcohol which will blacken the solution and 
foam badly. Twenty cc. of pure sulphuric acid are then added and one continues 
as in the Kjeldahl nitrogen determination. 

The amount of nitrogen multiplied by 2.143 will give the weight of the urea. 
Hoppe-Seyler advises that when the fluid is evaporated to 10 to 15 cc. about 
10 gms. of crystalline phosphoric acid be added, and one proceed as in the Schon- 
dorff method. 

A still better method is that of Schdndorf, 25 which gives results 
from 0.08 to 0.19 per cent, lower than by the Morner. This method is 
based on experiments that phosphotungstic acid will precipitate all of 
the nitrogenous bodies excepting urea; it would precipitate this in a 
solution of over 3 per cent. urea. 

Fifty cubic centimetres of urine (if the specific gravity be over 
1 01 7, it should be diluted) are measured in a closed graduated cylinder 
of 200 cc. capacity, and the acid mixture (phosphotungstic acid 10 
per cent. 9 parts, HQ specific gravity 1.124, 1 part) added until full 
precipitation is obtained. The amount necessary for this should be 
determined by the following preliminary test. To 10 cc. of urine is 
added the phosphotungstic acid mixture from a pipette, stirring by 
shaking, until 1 cc. of the clear filtrate (filter repeatedly until clear) 
does not cloud when a few more drops are added. It is sufficient to 
get within 1 cc. of the necessary amount. 

The cylinder is then filled up to the 150 or 200 cc. point with 
HC1 (of sp. gr. 1. 1 24, diluted ten times), well shaken, and allowed to 
stand for twenty-four hours. It is then filtered through a double filter 
until clear. The clear filtrate is rubbed up with Ca(OH) 2 until alka- 
line, and after the blue color disappears is filtered. Fifteen or twenty 
cubic centimetres (that is, the amount which corresponds to 5 cc. of 
urine) are then measured into an Erlenmeyer flask in which are put 10 
gms. of crystalline phosphoric acid. This is heated in a dry chamber 
(a sand-bath) for four and a half hours, the time reckoned from the 
point when all the water is evaporated off, and at a temperature of 
150 0 C. After cooling, the syrupy mass is dissolved in warm water, 
put into a distillation flask, and the further steps are the same as those 
of the Kjeldahl nitrogen determination. The amount of nitrogen mul- 
tiplied by 2.143 will equal the weight of urea in 5 cc. of the urine. 

Pfliiger and Bleibtren advise that 5 cc. of the filtrate, after the addition of 
Ca(OH)2, be used to make an ammonia determination, the nitrogen of which is 

25 Pfliiger's Arch., Bd. 62. 



116 



CLINICAL DIAGNOSIS 



subtracted from the result; but if pure phosphotungstic acid be used this is 
unnecessary since the ammonia will all be in the precipitate (Gullich). 

In all methods it is to be supposed other bodies nearly related to urea are 
determined as well. It has been repeatedly shown" 0 that if there be even o.i per 
cent, sugar in the urine there is a considerable loss of urea nitrogen, hence all must 
be removed by fermentation. 

Folin Method. 26 — To 5 cc. of urine in a 200 cc. Erlenmeyer flask are added 5 cc. 
concentrated HQ, 20 gms. MgCU, a piece of paraffin the size of a small hazel-nut, 
and 2 to 3 drops of 1 per cent, aqueous alizarin red. This flask, protected by a 
special safety-tube, is boiled till each drop of reflow makes a very perceptible thump ; 
the heat is then reduced and continued one-half hour. The contents of the flask 
/ must not turn alkaline, hence when seen to turn red a little of the acid distillate is 
allowed to flow back from the safety-tube. At the end of an hour the contents of 
the flask are transferred to a 1 litre flask with about 700 cc. water, then about 20 cc. 
of 10 per cent. NaOH added and then distilled until the last trace of ammonia has 
passed over. This will take nearly an hour and the flask will be nearly dry. 
The distillate is then boiled to drive off the CO-, cooled, and titrated. The 
ammonia of the urine and of the MgCU must be subtracted. 

LTsing the Schlosing method, v. Jaksch 27 has shown that among 
patients in general, 83.93 to 9 l -°7 P er cevit. of the total nitrogen is 
urea, and this constitutes from 95.85 to 98.36 per cent, of the nitrogen 
not precipitated by phosphotungstic acid ; from 1.52 to 3.61 per cent, 
of the total nitrogen is in amido-acids, and from 5.16 to 8.51 per cent, 
of the nitrogen precipitated by phosphotungstic acid is in amido-acids 
and ammonia bodies. To double the amount of total nitrogen is a 
sufficiently correct way of clinically estimating urea ; that is, he doubts 
any considerable disturbance of the distribution of nitrogen. 

The amido-acids are increased in liver disease, in typhoid fever 
(the output may be even 0.5 gm. per day), in diabetes mellitus (even 
to 0.64 gm. per day), and in some cases of Graves's disease. 

At this point we may suggest that simply because a person has a certain dis- 
ease it does not mean that that case will necessarily show the changes in nitrogen 
distribution usually ascribed to that disease ; for organs in general are functionally 
very sufficient despite disease until the disease reaches a point rendering them func- 
tionally insufficient, then the characteristic changes may suddenly develop. 

Halpern, 28 using similar methods, found in nephritis, carcinoma, 
and inanition a relative decrease of urea ; yet this was not constant, for 
in some cases he found normal figures, in others an increase of extrac- 
tives and ammonia but not of amido-acids; in liver disease there was 
no relation between urea and the amido-acids, although, the former 
fell ; in blood diseases, leuksemia, severe pernicious anaemia, and in 
tuberculosis, the distribution of nitrogen was normal. From the 
above results we see that in the usual run of cases the various 
diseases studied do not disturb the nitrogen distribution in any char- 

26 Landau, Maly, Jahresb., vol. xxxiii. 

27 Zeitsch. f. physiol. Chem., 1901, xxxii. p. 504; 1902, xxxvi. 
28 Ibid., p. 355- 



THE URINE: UBIC ACID 



117 



acteristic way. \Ye must wait for observations on a series of more 
severe cases of these same diseases. 

We give herewith a few of the properties of and tests for urea, since this 
is a most important body. Urea when pure occurs in crystals which are needles 
or prisms belonging to the tetragonal system ; colorless, striated, pale, four-sided 
columns with ends of one or two oblique planes, and sometimes hollow. They 
contain no water of crystallization. It is not hydroscopic, and does not change in 
the air ; it is decomposed by heat, the decomposition and the evolution of ammonia 
beginning at ioo° C, but chiefly at 130 0 to 132 0 C. 

The furfurol test is one of the most important. According to Schiff, one 
crystal, the size of the head of a pin, is brought in contact in a porcelain dish with 
one drop of concentrated aqueous solution of furfurol. At once is added one drop 
of hydrochloric acid (specific gravity 1.100) and one sees a rapid change of colors 
from yellow, to green, to blue, to violet, and in a few minutes a fine purple-violet 
color. Alantoin gives the same test, but less intense and slower. An old furfurol 
solution will also give the test without urea. Huppert advises the following 
method : 2 cc. of concentrated furfurol solution plus 4 to 6 drops of concentrated 
hydrochloric acid are mixed. The mixture must not stain red. To this is added 
one crystal of urea. In a few minutes is seen a deep violet color, which gradually 
becomes black, and then appears a black precipitate. 

The biuret test is one of the best-known urea tests. Urea, if fused, gives off' 
biuret and cyanuric acid. This occurs at a temperature of ioo° C. To test this 
a few crystals are put in a dry test-tube and heated gently until fluid. This is then- 
cooled, dissolved in water, made strongly alkaline with NaOH, and then 2 per 
cent. C11SO4 solution added drop by drop. A beautiful violet color will result. 

When only a crystal or so is at one's disposal, as, for instance, in the case 
of frost upon the skin, the best urea test is the nitric acid or oxalic acid test. 
Urea in the presence of concentrated nitric acid forms a compound, CO(NH 2 ) 2 - 
HNOs, in crystals, thin rhombs or hexagonal plates, which often overlap like 
shingles. They are colorless, and have acute angles. If they form slowly, large, 
thick, rhombic prisms are produced. These crystals heated volatilized without 
residue, an essential point in the test to exclude similar crystals of the heavy metals. 
No nitrous acid should be present in the nitric acid, since this in the cold will 
break up the urea, forming carbon dioxide, nitrogen, and water. To perform the 
test, one crystal or one drop of the concentrated solution is allowed to come in 
contact under the cover-glass with pure nitric acid. At the line of contact is 
seen the rapid formation of the above-described crystals. The urea must be in 
the concentration of at least 10 per cent. 

Urea oxalate, 2CO (NH 2 ) 2 H 2 C 2 C>4, is less soluble in water than the nitrate, and 
hence this test is preferred by many. It is performed in the same way as the nitric 
acid test. The crystals are rhombs, hexagons, or plates. It is well to dissolve 
the urea in the least amount of absolute alcohol, and to use a concentrated ether 
solution of oxalic acid, or, better still, an amyl alcohol solution of both. 

To isolate urea from any solution the albumin is first removed. The urine, e.g., 
faintly acid is concentrated at a low temperature to a very small volume; nitric 
acid is then added in excess, the mixture being kept cool. The precipitate is 
filtered and pressed between filter paper. It is then dissolved in water and decom- 
posed with barium carbonate, dried upon a water-bath, and the residue extracted 
with strong alcohol. The extract is decolorized if necessary with animal charcoal. 
Urea recrystallizes on cooling from the warm alcoholic solution. To determine it 
the Schondorff method is applicable to albumin-free fluids. 

Uric acid is a substance which has attracted an absurd amount of 
attention, and been the object of a great amount of careful work. The 
present status of opinion is that it is a specific oxidization product of 
the nuclein basis, and is increased only by an increase of these bodies 



118 



CLINICAL DIAGNOSIS 



in the food, or an increased metabolism of tissue nuclei. Horbaczewski 
considered that this body is derived especially from the nuclei of leu- 
cocytes. Although this may in some degree be true, yet it probably 
explains but a small part. It is an interesting fact that in birds and 
certain reptiles the uric acid is the chief nitrogen compound of the ex- 
crementa; that in some carnivora (dogs and cats) it sometimes fails. 
In the herbivora it is always present, but only in traces, and in man it 
is present in a larger but still very varying amount. It has been shown 
also that the body has the ability to synthesize uric acid. If hypo- 
xanthin be fed a patient, 50 per cent, will appear as uric acid. In the 
case of birds it is probable that just as in mammals the chief end 
product of nitrogen is urea, but this is synthesized to uric acid, while 
in mammals it is excreted unchanged ; and that, lastly, if uric acid be 
fed to the body it will oxidize some of it ; hence one is very wary in 
arguing from the amount in the urine to that found in the body. 
Recent work tends to show it an even more specific product of the 
nuclein bases than was supposed, and its output quantitatively related 
to these, although it is often delayed. 

Uric acid, when pure, is a white powder of very small prisms or 
plates. It is difficultly soluble in boiling water and very little in 
cold. It is more soluble if not pure. Urea is its best solvent, and this 
in the urine can hold all the uric acid there in solution. It is insoluble 
in alcohol and ether ; somewhat in hydrochloric acid and alkaline car- 
bonates. The cold solution does not redden litmus. It reduces Fehl- 
ing's solution when heated, but not bismuth solution. It is broken up 
by NaOBr, about 47.8 per cent, of its nitrogen being given off. The 
output may be said to vary normally from 0.2 to 1.25 gms., an average 
of 0.7 gm. in twenty-four hours, which represents from 1 to 2 per 
cent, of the total nitrogen. It is increased physiologically by an in- 
crease in the nucleins of the diet, sweetbreads being a favorite food 
to show this, since they increase it from 0.5 to 2 gms. in twenty- 
four hours. The maximum output occurs from three to five hours 
after a meal (that of the nitrogen in nine hours) . There is a relatively 
large output in the newborn. In the adult the nitrogen of the uric acid 
is to nitrogen of the urea as 1 : 50 to 70, but in the case of the newborn 
as 1 : 13 to 14. 

The amount varies considerably, particularly in different individ- 
uals. Burian and Schur have simplified the question greatly by 
showing that the uric acid output may be divided into two fractions, — 
the exogenous and the endogenous. By exogenous is meant the uric 
acid which is formed from the food directly ; the endogenous, that part 
arising from the tissue proteid. This endogenous fraction is therefore 
the interesting fraction to consider, and in metabolism work involving 
it the patient should be on a diet — e.g., of eggs and milk — which 



THE UEINE: UEIC ACID 



111) 



covers his nitrogen and heat needs, but which does not contain 
nucleins. 

Concerning the pathological variations there is the widest diver- 
gence of opinion, and hardly one claim is unchallenged. This is chiefly 
due to the fact that the difference between the endogenous and ex- 
ogenous was not recognized. 

The uric acid is pathologically increased when there is an increased 
proteid catabolism. Such is true of fever, in which case the increase 
is parallel to that of urea. 

There is an absolute increase in leukaemia, the record being that of 
Magnus-Levy's case, with an output of 8 gms. in twenty-four hours. 
As a rule, it is about 2 gms., and the nitrogen of the acid is to the 
nitrogen of the urea as 1 : 9. 

The relation in gout is still uncertain. One thing is quite certain, 
that during the quiescent interval between attacks the acid is below 
normal, rising to normal with the acute symptoms, then to sink again. 
This is of diagnostic importance in a suspicious case of arthritis. 
Whether it is retention of the acid or diminished formation followed 
by an increase is still to be settled, but the large accumulations of the 
acid in the tophi and around the joints is good evidence of an increased 
production; these patients do not respond as normally to an increased 
nuclein-rich diet by an increased uric acid output. 29 In rheumatism the 
question is still unsettled. In diabetes mellitus the increase is not 
marked, 2 to 3 gms., and is due to diet; in pernicious anaemia an 
increase is claimed. In pneumonia during resolution the output is in- 
creased, probably from the breaking down of the nuclei in a large ex- 
udate. In cirrhosis of the liver it is said to be very much increased, 
Chabrie even stating that in certain cases the maximum, even 8 gms., 
is excreted. This is rather interesting, since the liver is certainly an 
organ which can synthesize uric acid. The uric acid diathesis so 
emphasized by Haig is still in dispute. V. Jaksch thinks it exists, 
symptoms of hypochondriasis and increased uric acid output being the 
two features. 

It is said to be diminished by a poor diet, in nephritis, during the 
acute attack of gout, in certain chronic diseases, and after large doses 
of quinine. 

One point of interest is that when the alloxuric bases are increased 
the uric acid decreases in the same proportion. 
Urates. — The possible urates are : 

( 1 ) Neutral, MU, which do not occur in nature. 

(2) The monoacid or biurates, MHU, which are gelatinous or 
crystalline bodies, and the best illustration of which are the needles 
found in tophi in gout. 

29 Reach, Munch, med. Wochenschr., No. 29, 1902. 



120 



CLINICAL DIAGNOSIS 



(3) Quadriurates, MHUU, which are easily split to MHU and U 
by water, heat, or acid. They are less soluble than the biurates. The 
urate sediment is supposed to consist of this. Many observers think 
Roberts's quadriurates are merely mixtures of sodium biurate and uric 
acid. 

Tests. — The murexid test is the one commonly used. The uric 
acid is dissolved in two drops of nitric acid. This is evaporated care- 
fully to dryness, the residue being a beautiful red. Ammonia is then 
added and the color changes to a purple red. Had NaOH or KOH 
been used in place of the NH 4 OH, the color would be more of a blue 
or bluish-violet. The color disappears rapidly on warming, an im- 
portant point to differentiate certain other bodies. The test is more 
beautiful if evaporation is done over a water-bath, and if the ammonia 
be not directly added but placed in a small glass under a bell- jar near 
the residue; also if but little uric acid be used. If the residue be 
not red but only yellow, too little nitric acid has been added. More 
should be added and the evaporation repeated. 

Guanin, xanthin, epiguanin, will also give this test, but these are 
excluded if the substance used was insoluble in an excess of HC1. In 
confirmation the color should be bleached by further heating, and the 
Fehling's reduction test tried with the body. 

Quantitative Determination. — Only approximately this may 
be done by the Heller's albumin test, underlaying the urine with two- 
fifths volume of nitric acid. A cloudy ring appears above the line of 
separation. If the ring comes before five minutes, uric acid is in- 
creased; if after five minutes, it is decreased. The urine must be 
albumin-free. 

The most correct method is the Ludwig-Salkowsky. This method, as slightly 
modified by Schmoll, is as follows : 240 cc. of urine are precipitated by 60 cc. 
of magnesium mixture (100 gms. of MgCl 2 dissolved in water, plus NH 4 OH, till 
it smells strongly of ammonia. To this is added NH4CI until the precipitate is just 
dissolved, and the whole made up to 1 litre in volume). The mixture is then 
filtered, 250 cc. of filtrate (equalling 200 cc. of urine) are used, and precipitated 
with from 10 to 15 cc. of silver nitrate solution (1 litre containing 26 gms. of 
AgNOs and enough NH 4 OH to dissolve the precipitate. The volume is then made 
up to 1 litre. This should be kept tightly corked in a dark bottle). The urine 
is then filtered, the precipitate washed with distilled water, and then brought into 
suspension in a litre of water made just acid with HC1. Three to 4 cc. of CuSO* 
(10 per cent.) are then added and the mixture boiled. The silver salt is then 
decomposed by H 2 S while hot and just acid. After entire decomposition it is 
boiled and filtered and the filtrate evaporated to 15 cc. Ten to 15 drops of HC1 
are then added, and it is allowed to stand from one to two hours or more. 
The crystals of uric acid are then filtered out on a very small filter, washed with 
water slightly acidified with HC1, not too long, so that at the end the total volume 
of wash water is not over 40 cc. and the nitrogen of the precipitate on the filter paper 
then determined by the Kjeldahl method. The result multiplied by 3 will be the 
weight of uric acid. Or, the determination may be made gravimetric. The crystal- 
lizing solution is allowed to stand over night, and then is collected in a Ludwig 
glass wool or asbestos filter with a ground glass stopper, which has already been 



THE URINE 



121 



dried at no° C. and weighed. The precipitate is washed upon this, washing at 
first with the filtrate and then with the smallest amount of water, then with alcohol, 
then with CS 2 and ether, dried and weighed. 

This method, although the most accurate and one which with the small modifica- 
tions can be easily finished at the end of half a day, is still too difficult and demands 
too elaborate an apparatus to justify its use in general clinical chemistry. In a case 
of gout all that is necessary is to know whether the uric acid be much diminished 
or not, and a slightly less accurate method will suffice. Folin's modification of 
Hopkins's method is recommended. 

Folin's Method — To 300 cc. of urine are added 75 cc. of a 
uranium acetate reagent (consisting of 500 gms. of ammonium sul- 
phate and 5 gms. uranium acetate dissolved in 650 cc. of water ; 60 cc. 
of 10 per cent, acetic acid are then added and the whole made up to 1 
litre). This solution is to remove the phosphates and certain bodies 
not well understood whose presence would in certain pathological 
cases disturb the accuracy of the method. The urine thus treated is 
well stirred and allowed to stand' five minutes, and then filtered 
through a double folded filter; From the filtrate 125 cc. are measured 
into two beakers, each volume representing 100 cc. of urine. Five 
cubic centimetres of concentrated ammonia are added to each and the 
solution set aside until the next day. The clear fluid is then decanted 
through a filter, the precipitated ammonium urate is collected on the 
paper and washed with a 10 per cent, solution of ammonium sulphate. 
It should be washed until the filtrate is almost chlorine-free. In test- 
ing the filtrate of the washing for CI with AgNO s , a little HN0 3 
should be added. The filter paper is then pierced and the ammonium 
urate washed into a beaker, using about 100 cc. of water. Fifteen cc. 
of concentrated sulphuric acid are then added, and the solution titrated 
while still hot with a twentieth-normal KMn0 4 , until the first blush 
of red is seen through the whole volume of fluid. This color need 
last but a few seconds. Each cubic centimetre of the reagent indicates 
3.75 mg. of uric acid. A correction of 3 mg. per 100 cc. of urine 
it is necessary to add. 

By a twentieth-normal KMnCh is meant one of such concentration that 1 
litre would contain 0.05 gm. of available oxygen to oxidize the uric acid. Hence 
1.576 gms. of recrystallized KMnCL are weighed into 1 litre of water. Since 
weighing is not sufficiently accurate, it is best to make a slightly more concentrated 
solution. This is boiled, which renders the solution more permanent. It is then 
titrated against a tenth-normal solution of oxalic acid (6.3 gms. per litre) or 
potassium tetraoxalate (8.41 gms. per litre). Ten cc. of the oxalic acid solution 
are diluted to 100 cc. with distilled water, and 15 cc. of concentrated sulphuric acid 
added to produce a temperature of about 6o° C. The potassium permanganate 
is then added drop by drop until a uniform red color appears which lasts about 
thirty seconds. The permanganate solution is then diluted until 10 cc. of the 
oxalic acid require 20 cc. of the KMnOi solution for the end reaction. 

It is interesting that at the beginning of the titration the red remains longer 
than later. This is due to the fact that the combustion of the uric acid is much 
promoted by the increased percentage of the sulphate of manganese. The color 



122 



CLINICAL DIAGNOSIS 



is not permanent, owing to other reducing bodies, and the student, to use the 
solution satisfactorily, should have standardized it himself, that he may know 
what to consider an end reaction. 

To get an oxalic acid sufficiently pure it is necessary to recrystallize two to 
three times a cold saturated solution ; or, better, to recrystallize first from hot 
dilute HC1 (10 to 15 per cent.), then from hot alcohol, then from water. The 
aqueous solution must be heated till the odor of ethyl oxalate passes off. Oxalic 
acid cannot be dried in a desiccator or hot-air bath. 

In the above methods great care must be used to avoid error from the uric 
acid or urates which may have precipitated, and which must be redissolved by 
warming the urine, or by the addition of a little saturated lithium carbonate 
solution. 

Rudisch and Kleeberg 30 have recently reported a method for determining 
uric acid and the purin bases which they think even superior to the Ludwig- 
Salkowski method in accuracy, and so quick a method that it can be used clini- 
cally. These bodies are precipitated by an excess of fiftieth-normal AgNOs, and 
the excess of silver determined volumetrically by fiftieth-normal KI, the end reac- 
tion being recognized by testing, after the addition of the successive portions of 
KI, the mixture in test-tubes with nitrous-sulphuric acid (25 cc. H2SO4 to 75 cc. 
H2O, then 1 cc. of fuming HN0 3 ) and starch solution, until the blue of starch 
iodine compound appears. The separation of uric acid and the other purin bodies 
depends on the solubility of the silver compounds of the latter in strong ammonia 
solutions. This method is still recent, and for the details the reader is referred 
to the original article. 

The Purin Bases — The purin, alloxuric, xanthin, or nuclein bodies, 
all shown to contain the purin ring, occur in the urine in very small 
amount. Their formation from the nucleins is represented by the 
following diagram : 

Nuclein 



Simple proteid Nucleic acid 

Thymic acid Purin bodies 



Thymin Metaphosphoric acid 

Uracil 

Cytosin 

They are xanthin, guanin, hypoxanthin, adenin, heteroxanthin, 
paraxanthin, episarkin, epiguanin, methylxanthin, carnin. Of these 
ten bodies, the three which form the chief amount in the urine are 
heteroxanthin, paraxanthin, and methylxanthin, and these are derived 
wholly from the caffeine, theobromine, and theophylin of the food. 
Guanin and carnin are still unproved. The total amount occurring in 
the urine is from 15.6 to 45.7 mg. in twenty-four hours. Others con- 
sider 87 mg. an average output for a mixed diet (Camerer), 44 mg. 
for a meat and 1 1 1 mg. for a vegetable diet. 

Xanthin occurs normally in the urine only in minute traces. More rarely 
it is the chief constituent of urinary sediments and calculi, several of which have 

30 Amer. Jour, Med. Sci., 1904, vol. cxxviii. p. 899. 



THE UKINE: AMMONIA 



123 



been described. It is increased in leukaemia, nephritis of children, in which case 
there may be 28.5 mg. per 100 cc. instead of, as normally, 3.8 mg. From 10,000 
litres of urine 16 gms. have been isolated. 

The principal test of xanthin is Weidel's. The body in question is boiled in a 
test-tube with hydrochloric acid and a little KCIO3. It is carefully evaporated to 
dryness, and the residue moistened with ammonia. A red or a purple-violet color 
results. Another test is to evaporate to dryness in a porcelain dish with nitric 
acid, producing a yellow residue which, on the addition of NaOH and warming, 
becomes a purple red. 

Guanin is claimed to occur in the urine, especially in leukaemia. It gives the 
same nitric acid test as xanthin, excepting that the alkali gives a more blue-violet 
color. It does not give the Weidel reaction. 

Hypoxanthin is present in the urine and in considerable amounts in leukaemia. 
It gives neither the nitric acid nor the Weidel tests. 

Adenin occurs in urine, especially in leukemia. The characteristic reaction is 
that if the crystals be warmed slowly in an amount of water insufficient to dis- 
solve them, at 50 0 C. there appears a sudden cloud. It does not give the nitric 
acid nor the Weidel test. Its other reactions are the same as hypoxanthin. 

The quantitative determination used for these bodies is usually that of 
Salkowski. From 400 to 600 cc. of urine (albumin removed) are precipitated 
with a magnesium mixture and filtered. The filtrate is then precipitated with a 
3 per cent, ammoniacal silver solution (6 cc. per 100 cc. of urine). The silver 
precipitate is washed thoroughly. It is then brought into about 600 to 800 cc. 
of water, slightly acidified with hydrochloric acid and decomposed with H 2 S. 
The fluid is then heated to boiling and filtered hot. The filtrate is evaporated on 
a bath to dryness and the residue extracted with 3 per cent, hot sulphuric acid, 
from 25 to 30 cc. being used. This extract is allowed to stand for twenty-four 
hours. The uric acid is then filtered out and washed, the filtrate made alkaline 
and again precipitated with AgN0 3 . It is then collected on a small chlorine free 
filter, washed, dried, carefully ashed, the ash dissolved in nitric acid and titrated 
for chlorine by the ordinary Volhardt method. One part of silver equals 0.277 
parts of the xanthin base nitrogen, or 0.7381 parts of the xanthin bases. The 
uric acid can be determined in the same portion. 

The enormous literature on the xanthin bases has lost its value since the 
methods formerly used have been found incorrect, hence at present nothing can 
be said of the clinical value of these bodies. It is interesting, however, that in 
leukaemia these bodies have been found to be increased, also in tuberculosis ; and 
that there seems to be an antagonism between "them and the uric acid, so that while 
the sum of both remains constant, when one increases the other decreases, and 
vice versa. 

Ammonia. — There is always in normal urine a small amount of 
ammonia, varying from 0.3 to 1.2 gms. (average 0.7 gm.) in twenty- 
four hours on a mixed diet. This represents from 3.5 to 5 per cent, of 
the total nitrogen. It reaches its maximum percentage during sleep — 
that is, when digestion is at rest. The presence of this ammonia in 
normal urine should not be forgotten. It could be ammonia withheld 
from urea formation to balance acid ions, but this may not explain all, 
since there is still ammonia present after a long continued alkaline 
medication. 

Ammonia is one of the most important products of proteid metab- 
olism. In the arterial blood there is 0.4 mg., and in the portal blood 
1.85 mg. in 100 cc. (Hordynski). It is found in all the tissues, 
especially the stomach wall which contains 36.4 mg., and in the in- 



124 



CLINICAL DIAGNOSIS 



testinal wall 32.4 mg., per 100 gms. of the organ, being especially 
abundant at the height of digestion. In the other organs there is a 
more constant amount. It is rapidly changed to urea, especially by the 
liver, and hence in certain cases of disease, — e.g., cirrhosis and can- 
cer, — with the total nitrogen unchanged, the percentage of urea will 
fall and that of ammonia rise. These ammonia bodies may be sup- 
posed to cause a certain toxaemia when increased, since injected 
ammonia compounds are toxic, and dogs with the Eck fistula manifest 
symptoms of -toxaemia. 

The relation of N : NH 3 is quite constant on a constant diet, and 
is not affected by the amount of proteid. Much fat, however, does 
increase the percentage of NH 3 . During secretion of the HQ of the 
gastric juice the nitrogen per cent, rises. 31 

Ammonia is increased by the ingestion of inorganic acids and of 
organic acids which cannot be further oxidized, and by those which 
arise in the body, man and carnivora thus protecting their native 
alkalinity against depletion in acid intoxication. The herbivora can- 
not protect themselves as well, and hence suffer more quickly. Such 
acids may arise in considerable amount in the normal body if the 
diet be strictly proteid. It is increased in oxygen starvation ; in 
fever, during the febrile stage and continuing into the convalescence 
(Rumpf) ; in diabetes, in which case oxybutyric and perhaps diacetic 
are the acids present ; ammonia may be present in diabetes in from 8* 
to 12 gms. in twenty- four hours and represent from 25 to 40.4 per 
cent, of the total nitrogen. In a case of periodic insanity Edsall found 
a marked reduction just before the attack, and a rise as the attack 
came on. In certain cases of liver cirrhosis the ammonia is increased, 
since the liver fails to form urea. 

Dr. Williams has put the determination of ammonia to very prac- 
tical use in his obstetrical wards of this hospital. In cases of the 
pernicious vomiting of pregnancy the percentage of ammonia is much 
increased, even to 20 to 45 per cent., while in the cases of nervous 
vomiting, or reflex from the pelvis, and in eclampsia, it is not. With 
this very high ammonia percentage the urine need show no casts or 
albumin. Definite hepatic lesions are found. If this high ammonia 
percentage is found, the uterus is emptied, and the ammonia drops at 
once. In a normal pregnancy the ammonia percentage is somewhat 
increased, reaching a maximum during labor. 

Determination. — The Schlosing method is the one commonly 
used. (See Fig. 22.) This is simple, and yet is not perfectly satis- 
factory, since the results are somewhat too high. Twenty-five cc. 
of urine are mixed with 10 cc. of milk of lime. The broad vessel, B, 
in which this is placed, is at once covered over by a bell- jar, under 
31 See Schittenhelm, Deutsch. Arch. f. klin. Med., 1903, Bd. 77, p. 517. 



THE UEINE: AMMONIA 



125 



which have been previously put 20 cc. of tenth-normal H 2 S0 4 . The 
bell- jar is then well greased, to render it air-tight, and allowed to stand 
for from three to four days, during which time the milk of lime will 
have set free all of the ammonia which the sulphuric acid then takes up. 
It is well that the sulphuric acid dish, C, rest upon the dish contain- 
ing the urine. At the end of the three or four days the sulphuric acid 
is titrated against tenth-normal sodium hydroxide; the number of 
cubic centimetres multiplied by 1.7 mg. equals the weight of ammonia 
in 25 cc. of urine. If any moisture is present on the inside of the 
bell- jar the reaction of this should be tested, and if alkaline the entire 
interior of the bell- jar should be washed into the sulphuric acid before 
titration. 




Fig. 22. — Ammonia determination, Schlosing method. A, bell-jar ; B, dish containing urine; 
C, dish containing acid. 

The modifications proposed by Schaffer, working under Folin's directions, are 
the following : To 25 cc. of filtered urine are added 0.5 gm. of sodium carbonate 
plus an excess of sodium chloride. The sodium carbonate will not split off 
ammonia from any of the other nitrogenous compounds, as for instance urea, 
and the sodium chloride will prevent decomposition. The urine should be placed 
on a dish from 15 to 17 cm. in diameter that the layer be not over 2 mm. deep; 
a wide crystallizing dish or a wide Petri's dish is the most satisfactory. The 
time may be reduced to forty-eight hours if the apparatus be kept at 38 0 C 

Ammonia Determination. — Folin's Method (Zeitsch. f. phys. Chem., 1902, 
xxxvii. p. 161). — For this method a special apparatus is used. The ammonia is 
liberated by sodium carbonate. No heat is necessary. 

Twenty-five cubic centimetres of urine are measured into an aerometer cylinder 
(30 to 45 cm. high) and about a gram of dry sodium carbonate and from 5 to 10 
cc. of crude petroleum (to prevent foaming) are added. 



126 



CLINICAL DIAGNOSIS 



The upper end of the cylinder is then closed by a doubly perforated rubber 
stopper through which pass two glass tubes, only one of which is long enough to 
reach below the surface of the liquid. The shorter tube (about 10 cm. in length) 
is connected with a " calcium chloride tube " filled with cotton, which in turn is 
connected with a glass tube extending to the bottom of a wide mouth bottle 
(capacity about 500 cc.) which contains 20 cc. of N/10 H2SO4, 200 cc. of water, 
and the indicator. The special absorption bottle designed by Folin and pictured in 
Fig. 23 is very convenient and accurate, compelling a very intimate contact of the 
air from the cylinder with the acid in the absorption bottle. The absorption bottle 
is attached to a good filtering pump which can suck a very rapid air current. The 
air passing through the alkaline urine and then through the standard acid will in 
the course of about one and a half hours transfer every trace of ammonia to the 
acid. Its amount is then determined by direct titration with N/10 NaOH, using 
two drops of a 1 per cent, solution of alizarin-red as indicator and titrating to a 
red and not to a violet color. 




Fig. 23 — Folin's apparatus for ammonia and acetone determination. A, narrow tube for urine, 
connected by a tube containing cotton, with B, the cylinder containing acid. 

In none of the titrations should phenolphthalein be used as indicator, since 
this fails for ammonium salts. Among those which may be used are alazarin red, 
cochineal, and a dilute solution of hematoxylin, which is used by Steyrer and 
seems very satisfactory. 



Creatinin, the aldehyde of the creatin of muscle, occurs in the 
urine; creatin does not. In general its origin is the muscle of food 
and of the body. Its excretion is roughly parallel to that of urea; it 
is increased by a meat diet, and in hunger diminishes and even dis- 
appears. Sucklings have none in the urine until their diet is changed. 
It is probably increased by an increased metabolism of the body 
muscles. The relation between its output and muscular work has been 
much disputed, some claiming that it is increased only by excessive 
muscular work; others (Edsall) that it is increased by muscular ex- 
ercise, and diminished in extensive muscular paralysis and in patho- 
logical conditions associated with a marked decrease in the function of 



THE HEINE 



127 



the muscles; that while it is not a perfect index of the condition of the 
muscular metabolism, yet it is the index nearest the truth. Normally 
the output is about I gm. a day. Folin (Am. Jour, of Phys., 1905. 
vol. 13) has shown that the absolute quantity of creatinin eliminated 
in urine on a meat-free diet is a constant quantity, different for differ- 
ent individuals, but wholly independent of quantitative changes in 
the total amount of nitrogen eliminated. He found that moderately 
corpulent persons eliminated per 24 hours about 20 mg. creatinin per 
kilo of body weight, while lean persons eliminated about 25 mg. per 
kilo. Folin has also (Festschrift f. Olaf Hammarsten, iii, 1906) given 
good reasons for believing that creatin and creatinin are not very 
closely related ; that creatinin is a waste product, and that creatinin is 
really an important food. Amberg and Morrill (The Jour, of Biol. 
Chem. } 1903, vol. iii, No. 4) found in the urine of the new-born a 
small but constant amount of creatinin. 

Jaffes Test. — To the urine is added a little aqueous solution of 
picric acid and a few drops of dilute NaOH. An intense red color 
appears at once at room temperature and, increasing, remains for 
hours. If acid be added it becomes yellow. Acetone should be re- 
moved by boiling, since it gives a more reddish-yellow color and is 
much fainter. Glucose gives on warming a red color. The test is 
positive in solution of 1 to 5000. 

WeyVs Test. — To the urine are added a few drops of very weak 
sodium nitroprusside (sp. gr. 1003), then a few drops of weak NaOH. 
A ruby-red color appears which soon changes to yellow. Acetone 
will give a similar test and should be removed by heating, but the 
acetone urine would, if acetic acid be added, become of a cherry-red 
or purple-red, while in the case of creatinin the solution after adding 
acetic acid and heating becomes green and then a Berlin blue. The 
test is positive for 0.6 gm. per 1000. 

The most important compound of creatinin is the zinc salt (C 4 H 7 - 
N 3 0) 2 ZnCl 2 . Creatinin is a reducing body, reducing Fehling's after 
long boiling to a colorless solution, and after still longer boiling, if 
an excess of copper be present, precipitates Cu 2 (OH) 2 . Creatinin, 
therefore, disturbs the copper sugar tests since it is a reducing agent, 
and, more important, it holds the Cu 2 (OH) 2 in solution. Bismuth is 
not reduced. 

Quantitative Determination. — Salkowski's modification of Neubauer's 
method. — Of the urine, sugar- and albumin-free, 240 cc. are measured into a 
graduated cylinder, made faintly alkaline with milk of lime, carefully precipitated 
with calcium chloride and the whole then made up to 300 cc. After standing for 
15 minutes this is filtered until 250 cc. of filtrate (equal to 200 cc. of urine) are 
obtained. This is faintly acidified with HC1 and evaporated to about 20 cc. It is 
neutralized with soda, stirred up with 20 cc. of absolute alcohol, and then trans- 
ferred, and the dish well washed with absolute alcohol into a 100 cc. measuring 



128 



CLINICAL DIAGNOSIS 



flask. This is cooled, shaken from time to time, and then the flask is filled with 
alcohol to the 100 cc. mark. After standing for 24 hours the contents are filtered 
through a dry paper. Of the filtrate 80 cc. (which equals 100 cc. of urine) are 
mixed with 0.5 to 1 cc. of an alcoholic, absolutely acid-free ZnCl 2 solution (sp. 
gr. 1.2). The covered beaker then stands in a cool place for 2 or 3 days. The 
precipitate is then collected on a small, dry, weighed filter paper, washed with as 
little alcohol as possible, dried at ioo° C, and weighed. One hundred parts of 
ZnCl 2 -creatinin precipitate equal 62.44 parts of creatinin. Instead of weighing the 
nitrogen of the precipitate may be determined. 

Folin has published a colorimetric, quantitative method based on Jaffe's test. 32 

Creatinin — Folin's Quantitative Method {Am. Jour, of Phys., 1905, vol. 13, 
p. 48). — This determination is based on the color reaction which creatinin (and no 
other normal urinary constituent) gives with picric acid in alkaline solution. A 
high grade colorimeter is necessary, and Folin recommends that of Duboscq. 

The reagents necessary are: a N/2 solution of potassium bichromate (which 
will contain 24.55 S m - P er litre) ; a saturated picric acid solution (containing about 
12 gm. per litre) ; a 10 per cent, solution of sodium hydrate. 

Ten cubic centimetres of urine are measured into a 500 cc. volumetric flask, 
15 cc. of the picric acid and 5 cc. of the sodium hydrate solutions are then added, 
and the mixture is allowed to stand for five or six minutes. 

This interval is used to pour a little of the bichromate solution into each of 
the two cylinders of the colorimeter. The depth of the solution in one of the 
cylinders is then accurately adjusted to the 8 mm. mark. With the solution in 
the other cylinder a few preliminary colorimetric readings are made simply for 
the sake of insuring greater accuracy in the subsequent readings of the unknown 
solution. The two bichromate solutions must of course be equal in color, and in 
taking their readings no two should differ more than 0.1 mm. or 0.2 mm. from 
the true value (8 mm.) leaving out of consideration the very first reading made, 
which is sometimes less accurate. Four or more readings should be made in 
each case, and an average taken of all but the first. After a while one becomes 
sure of the true point, and can take the average of the first two readings. 

At the end of five minutes the contents in the 500 cc. flask are diluted up to 
the 500 cc. mark. The bichromate solution is thoroughly rinsed out of one of the 
cylinders by means of the unknown solution and several colorimetric readings are 
then made at once. 

The calculation of the result is very simple. It has been determined experi- 
mentally that 10 mg. of perfectly pure creatinin give under the conditions of the 
determination 500 cc. of a solution 8.1 mm. of which have exactly the same 
colorimetric value as 8 mm. of a N/2 bichromate solution. If then for example it 
takes 9.5 mm. of the unknown urine-picrate solution to equal the 8 mm. of the 

8.1 

bichromate, then the 10 cc. of urine contain 10 X — = 8.4 + mg. of creatinin. 

9-5 

If the 10 cc. of urine are found* to contain more than 15 mg. or less than 5 mg. 
of creatinin the determination should be repeated using correspondingly different 
amounts of urine, since outside of these limits the determination is much less 
accurate. 

With creatinin solutions the results are uniformly surprisingly accurate and 
Folin believes it equally reliable for normal urine at least. The determination 
takes less than fifteen minutes. 

Oxyproteinic and Alloxyproteinic Acids. 33 — The first of these bodies was 
isolated by Gottlieb and Bondzynski, and the latter by Bondzynski and Panek. 
Although these bodies have not been sufficiently studied as yet, and already some 
have been unable to confirm this work, yet their presence in normal urine is claimed 

32 Am. Jour, of Insanity, 1905. 

33 Bondzynski and Panek, Ber. d. d. chem. Gesell., 1902, vol. xxxv. p. 2959. 



THE URINE: CHLORIDES 129 

to be sufficient in amount to explain all or quite all of the neutral sulphur, which 
renders them very interesting. These writers, however, also think the oxyproteinic 
acid explains Ehrlich's Diazo reaction (see page 159). Their sulphur content is 
about 6 per cent. They stand the nearest to proteid of all the products of proteid 
metabolism, and yet give none of the proteid reactions. In amount of the alloxy- 
proteinic acid are excreted about 1.2 gms. per day, the oxyproteinic acid in about 
three times that amount. 

THE INORGANIC ACIDS AND BASES 

The Chlorides are one of the most important groups of solids in 
point of amount found in the urine. Measured as sodium chloride, 
there are excreted in twenty-four hours from 10 to 15 gms., seldom 
more. Chlorine is present in inorganic salts, the little claimed in 
organic compounds being much disputed, but with the weight of evi- 
dence against it. 34 

The source of the chlorides is the food. The amount excreted de- 
pends in the first place upon the amount ingested. Starvation will re- 
duce them to a trace. More is excreted during the day than during the 
night. Chlorine is increased by increasing the water output and by 
active exercise. It is diminished from loss of fluid by diarrhoea or by 
vomiting ; also by transudate and exudate formation, and increased as 
these fluids are reabsorbed, provided the absorption be rapid. In 
fevers it is diminished in a remarkable way, especially toward the crisis, 
following which, its increase, Sahli considers, is as important a sign of 
improvement as the lowering of the temperature ; in pneumonia some 
think the rise may be the first sign of improvement ; its entire absence 
a serious sign. A great diminution or absence of chlorides in the 
urine in a doubtful fever strongly suggests pneumonia. After the 
crisis the output soon returns to normal. The explanation is not clear. 
The drop is not due to the diet, since an increase in the amount of 
chlorine ingested is not followed by a corresponding rise, as normally. 
Among the reasons given are, that during fever the catabolism is of 
those proteids poor in chlorine; but it is found that chlorides per 
mouth or injected subcutaneously are also retained in the body; others 
say that they are retained in the exudates present, or again with re- 
tained water ; but the retention of the water is itself a much disputed 
point. Sahli considers that all these factors are present. A great deal 
of experiment has recently been done. There certainly is a definite re- 
tention of chlorides, but the reason is not the lack of absorption nor the 
food. The chlorine is not increased in the blood, but is accumulated 
in the other fluids of the body and in the tissues, being increased in the 
tissues of some cases with marked renal insufficiency to even four 
times the normal (Achard and Laubry). Van der Bergh 35 explains 
it as an attempt of the blood to maintain its osmotic tension, there 

^Ville and Moitessier, Compt.-rend. Soc. de Biol., liii. p. 673. 
56 M. J., vol. xxxi. 

9 



130 



CLINICAL DIAGNOSIS 



being an accumulation of the products of metabolism in the plasma 
due to a slight insufficiency of the kidney, which increases the osmotic 
tension of the blood, hence the chlorides do not enter the circulation, 
but remain fixed in the tissues. After convalescence has begun there 
is a sudden return to normal which Achard and Laubry name a 
" chlorine crisis." The sulphates and the phosphates do not return to 
normal at the same time. To these chlorine crises is attributed a prog- 
nostic value. 

We have examined the records of thirty-four cases of pneumonia in this 
hospital. It is our routine in almost every case of pneumonia (all on a pure milk 
diet, 1500 cc. q. d.) to determine the total amount of the chlorides daily. Six of 
these cases were with crisis. In two the chlorides showed a drop toward the 
crisis. In one case the crisis was preceded by a rise. In the other cases the rise 
began with, or even four or five days later than, the fall in temperature. In these 
very few cases it will be seen that we obtained very little prognostic value from 
the determination of the chlorides. In no case were the chlorides entirely absent. 
The average on the day before the crisis was 1.3 gms., varying from 0.7 to 2.1 gms. 
The greatest rise began on the fifth day after the crisis, on which day it varied 
from 3.8 to 4.9 gms. 

Of twenty-two cases of lysis, in seven-tenths of the cases there was a drop 
toward lysis. In two-tenths the chlorides began to rise one to two days before the 
temperature began to fall. On the first day of the lysis in ten cases there was 
above 1 gm., an average of 2.6 gms., and in one case 9 gms. In three cases they 
were absent before defervescence, and in two cases during the fall of temperature, 
hence in these cases entire absence was not a bad sign. They were lowest during 
the drop in one-third, and just before the temperature began to fall in two- 
thirds of the cases. They began to rise with the lysis in just one-half of the 
cases. The chief rise began after the temperature had reached normal. It was 
then rapid. 

In five fatal cases the chlorides fell steadily until the end in three and rose 
in one. In one case death was preceded by six days of entire absence of chlorides. 

In one case of delayed resolution the chlorides were interesting. Nineteen 
determinations were made during a period of twenty-two days. The lowest amount 
was 4.3 gms., and this occurred after the lysis. For the most part they varied 
from about 5 to 10 gms. per day, hence in this case there was comparatively little 
retention. 

In those cases in which the fall in temperature is succeeded by several days 
of very slight fever the chlorides do not rise until the temperature is about 
normal. In cases with a normal temperature but with a continuous slight leuco- 
cytosis they did not rise until this had fallen below 10,000. 

After chloroform inhalation the chlorides are increased. In dia- 
betes insipidus there is a marked increase with the polyuria. In all 
chronic diseases there is a decrease which may be due to disturbed 
absorption, or to the diet, or to the condition of the kidneys. 

In gastric disease the chlorine is diminished when there is con- 
siderable vomiting; when absorption is diminished, as in malignant 
pyloric stricture ; and when lost by lavage or diarrhoea. 

In chronic diseases, if the output becomes as low as 2 gms., and the 
diet cannot explain this, drop, it is an ominous sign, and the cessation 
of chlorine one of oncoming death. It is said to aid in the differen- 



THE TJKINE: CHLOEIDES 



131 



tial diagnosis between meningitis, in which the output is very low, and 
typhoid, where it is only moderately low. There is a marked diminu- 
tion in cholera, pyaemia, puerperal fever, and acute articular rheuma- 
tism. In cirrhosis of the liver it is said to be increased. 

The retention in nephritis has attracted especial attention, particularly in 
view of the recent work of Widal and others concerning cedema. Their explana- 
tion is that, given a slight renal insufficiency, there may be a specific retention of 
chlorides, the output of other solids remaining normal. These chlorides are re- 
tained by the tissues and there retain water, thus leading to cedema. By " chlor- 
uraemia" is meant a partial renal insufficiency for chlorine elimination, with a 
rapidly developing general cedema, low CI output, and increased albumin in the 
urine. It is rather hard, on this basis, to explain the absence of cedema after 
even a week of total suppression of the urine due, e.g., to calculus, or in those 
cases in which at operation the only functioning kidney is removed. The injection 
of physiological salt solution does not seem to cause cedema (perhaps since so 
dilute), and seems even to improve the condition of the case (Ferrannini) , but 
if increased albumin, slight hematuria, and sometimes ursemic convulsions follow 
the injection immediately, we cannot consider the injection harmless. We have 
repeated this work with varying success, but with none if the water intake be 
also controlled. This amount of salt makes the patient very thirsty and he con- 
sumes much more water. Achard and Loeper found that if 10 gms. of sodium 
chloride be given per mouth in acute nephritis, little or none of the ingested 
chlorine is excreted, the chlorides remaining low, from i to 2 gms. per day. In 
subacute nephritis with 4 to 10 gms. before the dose there is a slight increase, 
while in interstitial nephritis with 2.8 to 3.4 gms. output the most of that given is 
excreted. In uraemic conditions there may be little or none excreted. 

Estimation. — A rough estimation of the amount of chlorides 
is made in the following way : To a test-tube of clear urine which 
contains no albumin 10 drops of pure nitric acid are added and then 
one drop of AgN0 3 (i : 8). If the chlorides are normal or increased 
the precipitate is a compact ball which sinks to the bottom. If dimin- 
ished, this ball is less compact ; if much diminished, until only a cloud 
is produced without solid flakes. If the last be true, that is, a cloud 
merely, it means a chloride content of o. 1 per cent, or less. 

Quantitative Determination. — The best method is Arnold's 
modification of Volhardt's method. With the chlorides are estimated 
also the minute trace of cyanides. The principle upon which the test 
rests is the precipitation of hydrochloric acid by silver nitrate in a 
solution made strongly acid by nitric acid. An excess of silver 
chloride is added, and after the precipitate is filtered out the excess 
of silver is determined by titration with ammonium sulphocyanate. 
The urine should contain no nitrites, and most observers add also, no 
albumin or albumose, since these are precipitated as silver albumi- 
nates. If albumin be present, it may be necessary to ash the urine 
(Neubauers method). Hammarsten recommends that the albumin 
be removed by boiling with a trace of acetic acid. If this be done, 
however, the precipitate must be washed for some time in order that 
the abundant chlorides retained in the precipitate may be regained. 



132 



CLINICAL DIAGNOSIS 



Solutions necessary: 

(1) AgNO s . i cc. equals 10 mg. of NaCl. The pure crystalline 
AgNO s is used, i litre to contain 29.075 gms. of the salt. 

(2) Cold saturated solution of iron ammonium alum, or ferric 
sulphate, chlorine free (50 gms. of Fe 2 O e per litre). 

(3) HNO3. Specific gravity 1.2, chlorine-free. If chlorine be 
present the acid should be distilled. The nitrous acid should be 
removed by urea. 

(4) An ammonium sulphocyanate solution, 10 cc. of which will 
equal 10 cc. of the silver nitrate solution. To obtain this, 12.9 gms. 
of the NH 4 SCN are weighed and dissolved in a little less than one 
litre of water, and well mixed. Twenty cc. of the silver nitrate solu- 
tion, 5 cc. of the iron alum, and 4 cc. of nitric acid are mixed in 
a flask and then diluted to 100 cc. The ammonium sulphocyanate 
solution is then added from a burette. The first precipitate is brown, 
which at once gives place to a white precipitate of silver cyanate ; the 
brown ferric cyanate remains only after the last particle of silver has 
been precipitated. The end reaction is very sharp. The solution 
should then be diluted the necessary amount and the fluid again tested 
to make sure that 10 cc. of the silver nitrate solution equals 10 cc. 
of the ammonium sulphocyanate. Others recommend (v. Jaksch) 
that this latter solution be so made up that 25 cc. will equal 10 cc. of 
the silver nitrate, while others that 20 cc. equal 10 of the silver nitrate. 

In Arnold's method 10 cc. of urine are carefully measured with a 
pipette into a flask on the neck of which is a 100 cc. mark. Then 
are added 20 to 30 drops of nitric acid and 2 cc. of the iron alum 
solution. If necessary a few drops of 8 per cent. KMn0 4 are added 
until all red color disappears. The silver nitrate solution is then 
slowly run in, constantly shaking the flask until one is sure that all 
the chlorine has been precipitated and that there is an excess of 
silver. The flask is then allowed to stand for about ten minutes and 
then filled to the 100 cc. mark with water. This should then be 
mixed very thoroughly. There should be an excess of iron, other- 
wise the nitric acid can decolorize the ferric cyanate, but this excess 
of iron causes a brown rather than a red color in the end reaction. 
It is usually safe to add 20 cc. of the silver solution, while others 
recommend that 15 cc. be used. In general, a considerable excess 
gives the best results. 

After the observer is sure that the contents of his 100 cc. flask 
is thoroughly mixed, it is then filtered through a dry filter until 50 
cc. of clear filtrate are obtained. This is titrated with the ammonium 
sulphocyanate solution until the end reaction. The amount used in- 
dicates the excess of the silver solution in 50 cc. of filtrate. This 
amount multiplied by 2, since only one-half of the filtrate was used, 



THE URINE: CHLORIDES 



133 



and subtracted from the number of cubic centimetres of silver nitrate 
originally added, will give the number of cubic centimetres of silver 
nitrate actually precipitated by the chlorides of the urine. This 
multiplied by 10 mg. will give the weight of the chlorine as sodium 
chloride in the amount of urine used. 

Some add the iron alum solution to the 50 cc. of nitrate, not before. 
A much- jaundiced urine should be decolorized by adding a few drops 
of potassium permanganate and nitric acid. The urine is then warmed, 
allowed to stand for a few minutes, and filtered. 

Liitke Method. — In this method a tenth-normal silver nitrate solu- 
tion is obtained by dissolving 17.5 gms. of the silver nitrate in about 
900 cc. of 25 per cent, nitric acid. To this is added 50 cc. of a 10 
per cent, iron alum solution. The whole is then diluted to exactly 

1 litre with water. A tenth-normal ammonium sulphocyanate solution 
is obtained by dissolving 7.6 gms. of the salt in a little less than a litre 
of water and then titrating this against the silver nitrate, thus deter- 
mining its present strength, and then diluting, that 10 cc. of the one 
may equal 10 cc. of the other. Since the silver solution is weaker, 
at least 25 cc. is usually the amount used to give an excess. This 
method has the advantage of combining the three solutions in one. 
The mathematics involved is a disadvantage, since 1 cc. of the silver 
nitrate solution equals .00585 gms. of NaCl. 

The following: method of Purdy is less accurate and almost as difficult. 

To 10 cc. of urine in a graduated 15 cc. centrifuge tube are added 15 drops 
of HNO3, then AgN0 3 solution to the 15 mark. These are well mixed, then 
centrifugalized for three periods of five minutes each at 1500 revolutions a minute. 
The percentage of chlorides may then be read, using a table of values given in the 
last edition of his book. This volume of the precipitate is then by no means the 
smallest, as a little longer centrifugalization will show. 

Phosphates. — Phosphoric acid occurs in the urine of man in con- 
siderable amount, and is often encountered as the precipitate in an 
alkaline urine, a constituent of some of the most common crystals, and 
the principal ingredient of some of the commonest stones. In addition 
to the mineral phosphate there is always a little phosphorus in organic 
combination. 

The amount weighed as P 2 O s in the urine of an adult is from 1 
to 5 gms. in twenty-four hours, with an average of about 3.5 gms. 
The earthy phosphates are estimated as 1 to 1.5 gms., the alkaline from 

2 to 4 gms. It varies chiefly with the food, especially with its content of 
calcium and magnesium, since these in the intestines form insoluble 
phosphates, which are little absorbed, hence the output may be less 
than one gramme. It is for this reason that in certain of the herbivora 
phosphoric acid is present only in a trace. It is important in meta- 
bolism experiments to control the diet carefully, that one may be sure 



134 



CLINICAL DIAGNOSIS 



that an approximately constant amount will be absorbed. Ehrstrom 
considers, however, that the calcium of the food is not as important 
as early studies led one to believe, and thinks that acid calcium phos- 
phate can be absorbed in considerable amounts. Nevertheless, from 
the stools he could recover from 12 to 50 per cent., an average of 
30 per cent., of the total phosphorus ingested. 

The phosphates are increased by an increased metabolism of the 
body tissues, and also by a nuclein-rich diet. The amount from 
this source, however, is small. They are increased by hard muscular 
work. In starvation the phosphorus falls a little, yet more is excreted 
relative to the nitrogen, and in this condition the relative value, that 
is P 2 0 5 divided by N, equal 0.18. Ehrstrom found that the phos- 
phorus was not excrqted parallel to the nitrogen. In dogs on a pure 
meat diet the nitrogen is to the phosphoric acid as 8.1 : 1. 

Clinically the phosphates have been- the subject of much discussion. 
Some state that they are increased in extensive disease of bones, as 
rickets, osteomalacia, diffuse periostitis, etc., but concerning each of 
these diseases there is a great dispute. Some say they are increased in 
destructive disease of the lungs, especially early tuberculosis, but this 
also is open to considerable doubt, for the coincidence of disease 
and increased phosphoric acid output may be accidental. The same 
may be said of extensive disease of the nervous system. In men- 
tal disease Folin and Shaf e'r 36 found that during the periods of 
excitement the relative amount of phosphoric acid was diminished, 
but absolutely there was little change. They consider that the phos- 
phorus metabolism of the brain is disturbed on the excited days, and 
that there is a compensatory increase on good days. It is also in- 
creased in meningitis, yellow atrophy of the liver, in diabetes mellitus 
and insipidus, after the use of chloral, KBr, and lastly in phosphorus 
poisoning. 

They have been found diminished in acute diseases, for instance in 
pneumonia, during the height of the fever ; this is true especially of 
the earthy phosphates, which point Gouraud considers may aid in 
the differential diagnosis between tuberculous processes, in which 
case the earthy phosphates are increased, and pneumonia. At the 
crisis comes a sharp rise, but one not always simultaneous with the 
rise in nitrogen and chlorine, while the ratio between the earthy and 
the total phosphates increases considerably. In one case of typhoid 
fever the total P 2 O s rose after defervescence from 1.5 to 13 gms. 
The output of phosphoric acid in fevers is not at all parallel to that 
of chlorine, and there occur sudden large outputs which are inde- 
pendent of the diet (v. Jaksch has found, however, that in the acute 
lobar pneumonia of children there may be increased phosphoric acid). 
36 Amer. Jour. Phys., vol. vii. p. 135. 



THE UEINE: PHOSPHATES 



135 



They are diminished in most chronic diseases ; in all renal diseases, 
due it is supposed to the renal insufficiency, Purdy stating that 
the diminution in phosphates is almost as constant a feature as 
albuminuria; in pregnancy, in which case it is attributed to the fetal 
bone formation ; and in gout, in which disease the line of phosphoric 
acid runs quite parallel to that of uric acid. Certain cases have been 
reported in which, without any sugar output but with all the symptoms 
of diabetes mellitus, there is a phosphate excretion of even as high as 
10 gms. in twenty-four hours. Such are cases of the so-called " phos- 
phatic diabetes." To deserve this name the output should be at least 
from 3.5 to 4 gms. per day. Teissier claims that these cases resemble 
diabetes, while others say they more nearly resemble neurasthenia. In 
some cases this is simply a temporary absence of the sugar which 
later appears, and as the phosphates fall. 37 A relative increase, 
formerly also passing under this name, in which P 2 0 5 : N : : 17 to 
20 : 100, occurs in malnutrition and starvation. 
(For phosphaturia, see page 105.) 

The organic phosphorus has been found by Mandel and Oertel not 
to be influenced by a phosphorus rich diet. They considered that its 
output is a good index of tissue catabolism. 

There are four groups of phosphate salts, — the diacid, monacid, 
normal, and basic, — the salts varying in solubility in the order in 
which they are stated, the diacid being the most soluble. The monacid 
salts of calcium and magnesia are precipitated when the urine is made 
alkaline. On heating the urine, a flocculent precipitate of the normal 
salts is often seen (basic, v. Jaksch), which must not be confused 
with the albumin cloud. It has been found that this precipitate on 
heating is always the calcium phosphate with a trace of CaOx and 
CaS0 4 , but never magnesium, since the calcium salts are more in- 
soluble than the magnesium salts. 

In leukaemia White and Hopkins 3S have found an absolute and 
a relatively (to nitrogen) diminished output, and they suggest a reten- 
tion of the phosphorus in the blood to build new leucocytes. In the 
new-born the proportion between nitrogen and phosphoric acid is from 
5 to 8 : 1. 

Of the normal phosphates that of greatest interest is the 
MgNH 4 P0 4 6H 2 0 in the beautiful coffin-lid crystals of triple phos- 
phate, which occur in all alkaline or amphoteric urines containing 
enough ammonia. 

The acidity of the urine, although due to many acid components 
and to an unknown degree to each, is, however, chiefly due to the 
phosphates. Normally 60 per cent, of the phosphoric acid is present 

37 See Ralfe, Lancet, March 5, 1887. 

38 Journal of Physiology, vol. xxiv. p. 42. 



136 



CLINICAL DIAGNOSIS 



as diacidphosphate, and 40 per cent, as the monacid salts, but the 
former varies from 34.9 to 74.2 per cent. In general it may be said 
that the urine is amphoteric if the diacid salts are from 30 to 50 
per cent, and the monacid from 70 to 50 per cent, of the whole. 

A common test, allowing an approximate determination of the phosphates, 
is made by filling a test-tube half full of filtered urine, adding ammonia, warming, 
and then allowing it to stand. If in from eighteen to twenty-four hours the deposit 
is from one-fourth to one-half inch deep the amount is normal, if less it is 
diminished. This is a precipitate of earthy phosphates. These are then filtered 
away, all of the filtrate put in the test-tube, and one finger's breadth of magnesium 
mixture added. The urine is then warmed and the precipitate of alkaline phos- 
phates allowed to settle. If during the same length of time the sediment is from 
one-half to three-fourths inch deep the amount is normal. 

The urine may be cleared of phosphates by precipitation with basic or neutral 
lead acetate. 

Quantitative Determination. — Uranium nitrate method. 

Phosphoric acid as a diacid salt is precipitated by uranium nitrate, 
and if cochineal be used as indicator the first excess of the uranium 
salt will give with it a green compound which serves as the end reac- 
tion. Uranium nitrate is preferable to the acetate, since its solutions 
are more stable, but even the nitrate is none too stable, and should be 
frequently restandardized. Since free nitric acid is liberated in the 
reaction, and this will dissolve a certain amount of uranium phosphate, 
sodium acetate is added in excess ; and that all the phosphoric acid 
may be present as a diacid salt, acetic acid as well. The boiling urine 
should be titrated, since the end reaction is quicker and sharper, giving 
a more decided green. 

Neubauer recommends that for greater accuracy the urine be precipitated 
with magnesium mixture and the precipitate washed on a small filter with dilute 
ammonia (water, 3 vols., 10 per cent. NH 4 OH, 1 vol.). The precipitate is then 
dissolved in acetic acid, diluted to 50 cc. with water, and the titration continued 
as with the urine. The results obtained are somewhat lower. 

Albumin and sugar may be present. The titer changes with the volume of 
reagent used. For instance, if 20 cc. are used, 1 cc. will indicate 4.98 mg. P2O5; 
21 cc, 5 mg. ; 40 cc, 5.14 mg. Hence the uranium nitrate fluid should be stand- 
ardized against a phosphoric acid solution of about the concentration of normal 
urine. 

The fluids necessary are, 1, a phosphate solution 50 cc. of which 
contain o. 1 gm. of P 2 0 5 . This is so difficult to prepare that we 
recommend that it be purchased from those chemists who make a 
specialty of such work. This is the standard solution. 

2. A solution containing 100 gms. NaAc and 30 gms. acetic acid 
in 1 litre of water. Five cc. of this fluid added to 50 cc. of urine 
will keep all the phosphates in the diacid condition and prevent the 
presence of free nitric acid. 



THE HEINE 



137 



3. An alcohol cochineal extract; the ground cochineal insects 
digested in 25 per cent, alcohol. 

4. Uranium nitrate solution, 1 litre of which contains 35.461 gms. 
of U0 2 (N0 3 ) 2 6H 2 0. This solution is standardized against solution 
1. Three gms. of NaAc are added, since this salt always contains 
some free nitric acid. One cc. of this solution will indicate 5 mg. 
P 2 0 5 , hence 20 cc. should give the end reaction with exactly 50 cc. 
of solution 1. 

To 50 cc. of the standard phosphate solution are added 5 cc. of 
solution 2, then a few drops of the cochineal tincture. The amount 
of indicator added is of moment, and a rather strong solution is de- 
sirable. This in an Erlenmeyer flask is brought to the boiling point. 
The uranium solution is then added to the boiling fluid in small 
amounts, shaking constantly. After each addition the precipitate is 
allowed to settle somewhat and the bottom of the flask studied for 
the first trace of green precipitate, the end reaction, which will first 
settle here. Having determined how much of this solution will exactly 
precipitate the phosphoric acid of 50 cc. of solution No. 1 it is then 
diluted to approximately the proper amount and then again for a final 
exact correction. Twenty cc. of this solution indicate 0.1 gm. of 

p 2 o 5 . 

For the estimation of phosphoric acid in the urine 50 cc. of urine 
are treated in exactly the above manner. If very accurate results are 
desired a table of corrections for the change in titer necessary for 
the volume used should be at hand to make the necessary changes. 
If the urine be colored or jaundiced, the end reaction will not be 
sharp, and it should be acidified with hydrochloric acid or nitric acid 
and decolorized with KMn0 4 . The urine should then again be neu- 
tralized. During the titration the flask should be kept on the water- 
bath or over the free flame to keep the fluid almost at the boiling 
point. Between each addition the precipitate should be allowed to 
settle that the first trace of green may be seen ; the longer it is allowed 
to settle the sharper the end reaction. 

Instead of the cochineal a 10 per cent, solution of potassium ferrocyanide 
solution may be used. In this case, after each addition of uranium nitrate one 
drop of the hot solution is brought into contact on a porcelain plate with one 
drop of this reagent. The end reaction is a brown precipitate. It should be 
remembered that this is not the same end reaction obtained by cochineal, but one 
considerably later, hence in using the fluids it is essential that one know with 
what indicator it was standardized. 

The determination is very satisfactory, and a class all using the same urine 
get very close results. 

Determination of the Acidity of the Urine. — The acidity of the urine is 
so much due to the presence of diacid phosphates that for many years the deter- 
mination of these salts was the most accurate way of determining the acidity. 

Freund's method is based on the fact that BaCl 2 will precipitate the monacid, 
but in the dilute urine not the diacid salt. If, therefore, the total phosphoric acid 



138 



CLINICAL DIAGNOSIS 



and the monacid salt be determined, the difference will be diacid phosphate. The 
method is not exact; the monacid-salt figure will be 3 per cent, too great. For the 
determination the above solutions are used ; also one of 100 gms. of BaCl 2 2H 2 0 to 
1 litre of water. The total phosphoric acid in 50 cc. of urine is determined. To 
75 cc. of urine the barium chloride solution is added till the whole is 90 cc. The fluid 
is then shaken well and filtered until clear. This may mean repeated attempts ; 
60 cc. of the filtrate (equalling 50 cc. of urine) are then used, the phosphoric acid 
determined and subtracted from the total. From the monacid phosphate is sub- 
tracted 3 per cent., which is added to the diacid. The acidity of the urine is 
expressed in terms of the diacid salts. 

Sulphates. — Sulphur is present in the urine in three forms, — (a) 
preformed or neutral sulphates; (b) ethereal or conjugated sulphates, 
that is, sulphuric acid combined with aromatic alcohols, indoxyl, ska- 
toxyl, cresol, phenol, et al.; (c) neutral, unoxidized, or organic 
sulphur. Weighed as SO s , a + b amount to from 1.5 to 3 gms., or an 
average of 2.5 gms. of H 2 S0 4 in twenty-four hours, in the case of 
a normal person on a mixed diet. As a rule, the ethereal sulphates 
are about one-tenth of the total sulphates. Since practically all of 
the sulphuric acid is a product of proteid metabolism, the output should 
be parallel to that of nitrogen, and the ratio between them is quite 
constantly 5 : 1 to 5 ( 100 : 19.1 to 20.4, Folin). But this is not exact, 
since the sulphur contained in proteids varies, and the amount of 
sulphur excreted in the neutral form varies as well. 

The total sulphate output depends especially upon proteid metab- 
olism, being increased in all conditions increasing proteid oxidization; 
hence there is none in the urine of the foetus. It is especially depend- 
ent on a meat diet. It is increased by exercise, providing this 
increases the nitrogen output as well. It is increased in fevers, since 
in this condition there is an increased proteid catabolism. The in- 
crease is especially marked in acute inflammatory disease of the brain 
and cord, and in acute articular rheumatism. It is increased after 
protoplasmic poisons. It is diminished during convalescence from an 
acute fever and in practically all chronic diseases. The amount of 
total sulphates has very little clinical value. 

The ethereal sulphates are of considerable interest. While their 
output is subject to great and inexplicable variations, they may be 
considered as an accurate index of the amount of absorption of the 
products of intestinal decomposition which can pair with the acid. 
They are independent in great degree of the neutral sulphates, and 
with the total sulphate their ratio varies so considerably that normal 
limits cannot be stated, hence it is their absolute amount which is of 
more value than their relative. 

This amount varies in the first place with the food. They are in- 
creased in the urine of a dog fed on foul meat ; are diminished during 
hunger and long fasting ; they are diminished on a milk diet, in which 
case it is supposed that casein inhibits the bacteria of decomposition. 



THE UEINE: SULPHATES 



139 



Intestinal decomposition increases them relatively and absolutely. 
This increase is diminished much by calomel and similar drugs. The 
decomposition of proteid furnishes phenol, cresol, indoxyl, skatoxyl, 
hydrochinin, pyrocatechin, and several other bodies ; the most im- 
portant, indol and phenol, explaining only about one-fifth, and a large 
percentage is still unidentified. They are increased by the ingestion of 
aromatic bodies, and particularly of carbolic acid. There is almost none 
in the urine of newborn. The output varies to a great extent with the 
hydrochloric acid of the gastric juice and the sodium chloride of 
the food. After hydrochloric acid medication they are diminished, 
and are increased by alkaline drugs. 

Pathologically, they are increased in chronic intestinal catarrh and 
diminished in acute. They are increased sometimes in constipation, 
sometimes there is no change. In a recent interesting case of " black 
urine" (see page 102), from a case of extreme constipation, the total 
sulphuric acid (as S0 3 ) was only 0.147 gm. per 100 cc. of urine, and 
of this, 57 per cent, was ethereal sulphate; the following day the 
urine was of normal color, total S0 3 , 0.086 gm. per 100 cc, and 50 
per cent, of this ethereal sulphate. They are increased in those cases 
with defective absorption from the intestine, as in typhoid fever, intes- 
tinal tuberculosis, and peritonitis. They are increased in cholera, but 
during the stage of reaction there may be little or none present. In 
atrophic liver cirrhosis and carcinoma of the liver the increase is 
attributed to the accompanying intestinal catarrh. They are also 
increased if decomposition occurs in other parts of the body than 
the intestine. It is of interest that in gastric disease, even with much 
stagnation and fermentation, they are little affected. 

The unoxidized sulphur is supposed by some to vary with the 
amount and quality of the food ; by others to have relation not to food 
but to tissue destruction, to be increased by muscular work, the lack 
of oxygen, and the ingestion of various sulphur compounds, including 
the flower of sulphur, sulphonal, methylmerkaptan and ethyl sulphide. 

This neutral sulphur, which amounts to from 14 to 25 per cent, 
of the total sulphur, is present in two forms : about 20 per cent, is the 
easily oxidizable, which is oxidized by bromine or chlorine (bromine 
is better, since chlorine attacks also the taurin derivatives), and the 
difficultly oxidizable. For the total the residue must be fused with 
KNO3, since fuming HN0 3 does not oxidize all of the neutral sulphur. 
In cystinuria HQ plus KN0 3 will oxidize only from 30 to 40 per cent. 

In jaundice from 24 to 60 per cent, of the sulphur is neutral, and of 
this there is an increase of about four to five times the normal propor- 
tion of the difficultly oxidizable form. In pneumonia the increase is of 
the easily oxidizable, and in liver disease the opposite. In cystinuria 
even 45.7 per cent, is neutral sulphur (in one of our cases 32 per cent.). 



140 



CLINICAL DIAGNOSIS 



Edsall 39 carefully studied the easily split (by alkali) sulphur in a 
series of cases. His results were negative. He decided that cystinu- 
ria is the only disease with an increase in this sulphur fraction, and 
that the relative proportion of these two fractions has no clinical value. 

Petry studied the question in dogs on a known diet, and found a 
quite constant amount (5.5 per cent.) of the total sulphur to be the 
easily split. This amount could not at all be influenced by diet. 

Recent work by several (e.g., Benedikt) 40 has emphasized the in- 
dependence between the excretion of neutral and total sulphur, the 
former remaining almost constant whatever the diet. It is suggested 
that the neutral sulphur arises in the catabolism of particular proteids. 

Detection and Approximate Estimation. — If in a test-tube 
holding over 25 cc. the urine is mixed with about one-third its volume 
of an acid barium chloride solution (BaCl 2 , 4; HQ, r; H 2 0, 16 
parts), a precipitate of the barium sulphate is formed. If this be a 
milky turbidity, the sulphates are normal; if creamy, increased; if 
merely a translucency, diminished. If allowed to settle from eighteen 
to twenty-four hours, and the precipitate fills one-half the concavity 
of the tube, they are normal. The above are the neutral sulphates. If 
this be filtered, and to the filtrate hydrochloric acid be added and the 
whole warmed, the ethereal sulphates are split and precipitated. 

Quantitative Determination of Total Sulphuric Acid. — In 
the gravimetric method the barium salt is weighed. The ethereal sul- 
phates must first be broken up by heating the urine with HQ. The 
precipitation must occur in hot solution and in the presence of free 
acid. The best concentration for filtration is a solution of not more 
than o. 1 per cent. BaS0 4 . The chief difficulty in the whole process is 
to rid the precipitate of the barium nitrate, which it holds very fast. 

Twenty-five or 50 cc. of urine are filtered, diluted from two to three 
times and from 5 to 10 cc. of hydrochloric acid per 100 cc. of fluid 
added. It is then heated to the boiling point for about fifteen minutes. 
Barium chloride is then added in slight excess. Huppert recommends 
that the beaker remain on the water-bath for several hours until the 
supernatant fluid is perfectly clear. It is then allowed to stand cold for 
twenty-four hours, that the salt held in solution by the hydrochloric 
acid may be completely precipitated, for BaS0 4 , so insoluble in water, 
is somewhat soluble in HC1. The clear fluid is then decanted through 
a small ashless filter, the precipitate mixed with boiling water, and 
again allowed to settle until clear. This decanting is continued until 
the filtrate gives no clouding with silver nitrate. The precipitate is 
then brought on the paper, washed with hot water, hot alcohol to re- 
move resinous matter, and then with ether. It is warmed, and dried to 

39 Univ. of Penn. Med. Bull., 1892, iii. p. 87. 

40 Zeitschr. f. klin. Med., 1899, vol. xxxvi. p. 281. 



THE UEINE: SULPHATES 



141 



ioo° C. The precipitate is then separated from the filter onto a piece 
of glazed paper, the filter paper burned in a platinum spiral, and the ash 
added to the precipitate. This is then put into a platinum crucible and 
well burned. The crucible is then allowed to cool, a drop of sul- 
phuric acid added, and again brought to a red heat. It is then cooled 
and weighed; again a drop of acid added, and the above continued 
until at constant weight. One hundred parts of BaS0 4 equal 34.28 
parts of SOo, 41.13 of S0 4 , 41.99, H 2 S0 4 . 

The hydrochloric acid, it is said, should be distilled, since it may contain a 
little sulphuric acid. The crucible should be heated by an alcohol flame, since 
illuminating gas may contribute to the sulphur in the crucible. Huppert recom- 
mends that, to avoid the loss of a certain amount of the BaSCU by its solubility 
in HC1, the HC1 first be added, the urine then heated, then diluted with water and 
precipitated by the BaCL. In this way less hydrochloric acid is used. 

The above method is long and tedious. The way recommended by 
Dr. Jones we have found much more satisfactory. The precipitation 
occurs in an Erlenmeyer flask covered by a watch-crystal ; the fluid 
is then boiled vigorously over a free flame for about half an hour. The 
precipitate is then brought at once onto the filter paper, since there is 
little danger of its passing through. The S. & S. blue ribbon filter 
paper should be used. 

Ethereal Sulphates. — These have been separated into those 
easily split and those difficultly split, according to whether heat is 
necessary for the cleavage by hydrochloric acid. They are not split by 
acetic acid. 

The former are decomposed by HC1 on standing in the cold for 
twenty-four hours. Such are compounds of indol,, skatol, etc. Com- 
pounds of phenol, kresol, et ai, are decomposed on the water-bath only. 

Baumann recommended that to 50 cc. of urine be added acetic acid, 
and then an equal amount of water, and BaCl 2 in excess. This is then 
warmed over the water-bath from a half to three-quarters of an hour 
or until clear. It is filtered, washed, and the filtrate treated as for 
the total. The final weight will be that of the ethereal sulphate. To 
save time, since this precipitate passes easily through the filter, it is well 
to bring the mixture into a measuring cylinder and dilute to an easy 
volume, and then decant through a filter a given amount of the clear 
supernatant fluid. 

Salkowski's method is much easier to apply. To 50 to 100 cc. of 
urine are added an equal amount of Ba mixture ( 1 volume cool 
saturated BaCl 2 plus 2 volumes cool saturated Ba(OH) 2 ). This is 
then filtered through a dry filter into a dry beaker. Fifty or 100 cc. 
of nitrate (equalling 25 or 50 cc. of the urine) are used. Hydro- 
chloric acid is added until strongly acid (15 cc. to 100 of the filtrate) 



142 



CLINICAL DIAGNOSIS 



and it is heated nearly to the boiling point. The further steps are the 
same as for the total sulphur. Kossel 41 has shown the possibility of 
certain errors in this method. 

Neutral Sulphur. — Neutral sulphur may be determined in the 
filtrate of urine used for the total sulphuric acid, but it is much better 
to determine the total sulphur, and from this subtract the total sul- 
phuric acid. 

Total Sulphur. — Fifty cc. of normal urine (or 25 cc. of urine 
containing cystin) are evaporated to dryness. To the residue in a 
silver crucible is added a mixture of four parts potassium nitrate and 
1 part of sodium carbonate (both sulphur free), and the whole burned 
until white. The residue is dissolved in water and poured into a por- 
celain dish, and the crucible well washed. It is then evaporated at least 
three times, adding hydrochloric acid each time to get rid of the nitric 
acid, all of which must be removed since nitrates are carried down in 
the precipitate and cannot be washed out. The residue is then dis- 
solved in water, and allowed to stand, to see if any AgCl separates ; if 
it does, filter. It is better to evaporate the urine almost to dryness 
before the addition of oxidizing mixtures, since the evaporation occurs 
more rapidly. Certain makes of porcelain crucibles can be used instead 
of silver, but the majority will break. 

A method theoretically much better is Asboth's modification of the Hohnel- 
Glaser method. In a nickel crucible are mixed about 1 gm. of the dry residue 
of the evaporated urine, 7.5 gms. of soda, and 10 gms. of sodium peroxide. The 
mixture is then heated over an alcohol lamp, the flame of which must not touch 
the crucible until perfect fusion. It is then heated to a thin fluid. This is 
allowed to cool, is dissolved in water, acidified with HC1 containing some bromine, 
boiled till all the bromine is driven off, filtered into a beaker, and precipitated hot 
with a hot solution of BaCk This method is advantageous, since no nitric acid 
is used. On the other hand, sodium peroxide is a violent explosive, hence the mix- 
ture with soda. 

The oxidization is also done by diluting the urine with an equal 
amount of hydrochloric acid and then evaporating on a water-bath, 
from time to time adding a knife-point of KC10 3 . When at dryness 
more HC1 should be added and more KC10 3 , until the residue on dry- 
ing does not contain any brown particles. This method is easy, since 
no nitric acid is used. That, however, it gives the same result as the 
other methods we decidedly doubt, and are at a loss to explain the 
agreement which others have found. 

In a series of metabolism experiments we used always both this and the fusion 
with KNOs and soda, and were at a loss to explain their lack of agreement. In 
collating all our results we found, to our surprise, that the difference was almost 
a constant, the HCI-KCIO3 method giving about 80 to 85 per cent, of that by the 

41 Zeitschr. f. physiol. Chem., vii. p. 296. 



THE TJKINE 



143 



KNOs-soda method, and this true, although the totals differed considerably. This 
may throw some light on the sulphur distribution. (See below.) 

Easily Oxidized Sulphur. — Jerome's method. To 50 cc. of 
urine are added 40 gms. of KC10 3 in a flask, and this warmed on a 
sand-bath with the addition from time to time of small portions of 
100 cc. of HC1. The solution is evaporated on a porcelain dish to dry- 
ness and is then evaporated with 100 cc. of HC1 three times. It is then 
filtered and the process continued as for sulphuric acid. It will be 
noted that this old method for easily oxidizable sulphur is that which 
recent workers have used for total sulphur. (See above.) 

Thiosulphuric Acid, H 2 S 2 0 3 . — Normally there is in the urine of man none, or 
not over 10 mg. in i litre. It has been found, however, in some cases, as, for in- 
stance, in typhoid fever. 

Hydrogen Sulphide, H 2 S. — This seldom occurs in fresh urine. It has, 
however, been found, and by it have been explained cases of autointoxication. 
It was found in one case of long-standing eclamptic coma. It soon appears, 
however, in a urine on standing, and can be produced in any normal urine by 
warming it with a mineral acid. It does not occur in disease with decomposition 
in the intestine, nor after the ingestion of alkaline sulphides, nor after sulphur 
baths. While it is doubtful whether it can reach the bladder from the rectum, 
it can arise in the bladder from fermentation processes. It develops in the urine 
from decomposition due to organisms, at least eight of which have been described 
as specific. Muller considers that it is derived from the unoxidized sulphur. It 
may be detected in the fresh urine by the odor, or by suspending in the mouth 
of the flask a strip of paper moistened with sugar of lead solution plus one drop 
of NaOH. Air should then be aspirated through the urine. The paper will be 
blackened. 

Sulphocyanic Acid, HSCN. — This acid occurs normally in the urine of man 
and the animals which excrete nitrogen as urea, in amounts equalling about 
one-third of the neutral sulphur. The amount seems constant in an individual, 
but varies in different persons. It is increased by the inhalation of CS 2 even 
fifty times. 

To 100 cc. of urine are added HNO3 and AgN0 3 . The precipitate is filtered, 
washed, suspended in water, decomposed with H 2 S, and the filtrate distilled. The 
distillate is tested with Fe 2 Q 6 , giving an intense blue fluid (Berlin blue) not modi- 
fied by HC1. 

Carbonates. — Carbonic acid is present in the urine, both free, which may 
be removed by a vacuum, and bound, in which case acid must be added to free 
it. Of the free there are about 180 cc. of C0 2 ; of the bound, from 2 to 10 cc. 
The carbonic acid is increased by a diet rich in organic acids which are oxidized 
to carbonates, hence it is present in great abundance in the alkaline urine of 
herbivora. In urine there is little in solution, the most being united with a base, 
and its solubility depends on the relative amount of CO2 and MfLPCX; if some 
of the C0 2 is removed by a vacuum, the acid phosphate at once sets more C0 3 
free until none is left. The carbonic acid may be determined by drawing a stream 
of air through the urine and then through clear baryta water, which it clouds at 
once. If, then, the urine be acidified, the bound C0 2 will be free. The amount of 
CO2 is greatly increased as the urine begins to decompose, a point quite disturbing 
in all quantitative work. In some cases of nephritis, especially if on an alkaline 
treatment, the urine is alkaline when voided, and contains so much carbonate that 
quantitative work is impossible. 

Silicic Acid is present in traces as silicates. Its source is the food. 

Nitric Acid is present in all normal urines as nitrates. This also is from the 
food and especially certain vegetables. 



144 



CLINICAL DIAGNOSIS 



Nitrons Acid is often found as nitrites, but is reduced from the 
nitrates by the bacteria. 

Calcium and Magnesium. — These alkaline earths are excreted as 
phosphates to the amount of about i gm. per day; calcium, weighed as 
CaO, about 0.12 to 0.25 gm., and MgO from 0.18 to 0.28 gm. per day. 
The calcium excretion, even of that injected subcutaneously, is chiefly 
through the intestines, and from but 4 to 29 per cent, through the 
urine. On this account the calcium in the urine is no index of the 
amount absorbed from the intestine. In the urine its output is parallel 
to that of the ammonia, and it seems to bear some relation to the excre- 
tion of acids. In this connection it is of interest that most is excreted 
in the morning, at which time the urine is most acid. Its chief source 
is the food. During starvation periods calcium is increased relatively 
and absolutely, which is of interest since there is also then a slight 
acidosis. The source of this calcium is assumed to be the bones. It 
can be decreased by alkaline treatment. On a vegetable diet there is 
only a trace of calcium in the urine. It seems increased by exercise. 

The factors influencing the output of calcium are little understood, 
and yet much would indicate that the calcium bears some relation to 
the condition known as acidosis (see page 203). There is no increase 
in tuberculosis, and none in rickets. In chronic diseases the in- 
crease can be explained by inanition. In diabetes an interesting 
behavior of this metal was demonstrated by Gerhardt and Schlesinger, 
who by very careful metabolism work confirmed the previous find- 
ings that the output is in diabetes increased even two to four times 
the normal amount ; that the output is parallel to that of ammonia 
and can be diminished by alkaline treatment ; and that in those cases 
with acidosis it is especially increased ; the normal ratio between the 
intestinal and the urinary output is reversed in favor of the latter, 
while there seems a certain amount of retention of magnesium in the 
body. In the case of arteriosclerosis a retention of calcium has been 
demonstrated. 

The relation of this metal to phosphaturia is interesting, since that 
symptom-complex would seem to be due more to an increase of calcium 
with a diminution in the phosphoric acid than to an increase of the 
latter. 

Quantitative Determination of Calcium. — Two hundred cc. of filtered urine 
are made alkaline with ammonia until there is a distinct precipitate. This is then 
dissolved in the smallest amount of hydrochloric acid with the addition of some 
NaAc. Ammonium oxalate is then added in excess and the fluid allowed to stand 
covered on a water-bath for twelve hours. The precipitation of calcium phosphate 
which occurs if no ammonium be added or if the urine be foul should be avoided. 
The supernatant fluid is then decanted through a small ashless filter, the precipitate 
washed CI free by decantation with hot water, and then finally brought on the 
paper. The precipitate of CaO is very fine and apt to pass through the paper, 



THE URINE 



145 



hence is washed as much as possible by decantation. The wash-water may be 
saved for magnesium determination. During this process bacterial fermentation 
should be prevented by. thymol or carbolic acid. The dry filter paper is then put 
in a platinum dish, burned moderately for a long time, then at a dull red, till the 
mass on cooling is perfectly white. It now contains some oxide. It is moistened 
with a concentrated solution of ammonium carbonate, slowly dried, and very 
gently ignited. The treatment with ammonium carbonate is repeated till of con- 
stant weight as calcium carbonate. One part of CaC0 3 equals 0.40 parts of Ca. 
Or the mass may be burned white with a blast-flame. The crucible is then cooled 
and weighed and the blast repeated until the weight is constant. The precipitate is 
now CaO, 1 part equalling 1.845 of calcium phosphate. Or the precipitate is burned 
white, then concentrated ammonium sulphate added, again burned, and this repeated 
until there is no increase in weight. One part of this calcium sulphate equals 
0.41 176 part of CaO. 

Quantitative Determination of Magnesium. — For this the filtrate and wash- 
water of the above determination may be used. One-third volume of 10 per cent. 
NH4OH is added (sp. gr. 0.96), which will precipitate all of the Mg as NILMgPO*. 
This is allowed to settle well, collected on an ashless filter, washed with water 
plus one-third volume of ammonia, thoroughly dried, shaken into a platinum 
crucible, the paper burned in a platinum spiral and its ash added to the crucible, 
and the whole then fused. Since there is some uric acid in the precipitate it will 
hardly burn white. It should therefore be cooled, a small piece of NH 4 N0 3 plus 
a few drops of water added, this warmed slowly, and then finally burned. The 
result is Mg 2 P 2 07. One hundred parts of this equal 36.208 parts of MgO. 

It is a saving of time to treat 200 cc. of the original urine in this way. The 
result is calcium and magnesium. The Ca is determined in a second portion, and 
the difference will be the Mg. 

Sodium and Potassium are present, of the former 4.2 to 7.4 gms. 
as Na 2 0 in twenty-four hours, and of the K 2 0 from 2.3 to 3.9 gms., 
the usual relation between them being 5:3. 

Their amount depends on the food. In hunger the potassium may 
exceed the sodium, also in fever, but after the crisis the sodium will 
predominate. 

Severe exercise and vegetable diet increase the potassium. 

Iron. — A trace of iron is always present in the urine in organic 
combination. The figures given of the amount found vary widely, 
since all methods have many sources of error, in many cases the iron 
of the reagent used being greater in amount than that to be deter- 
mined. The figures given vary from 1 to 10 mg. in twenty-four 
hours. This is increased in fever, the amount varying as the height 
and duration of the elevation of temperature. Large amounts have 
been found in malaria (even 16 mg. a day), pernicious anaemia, and 
alcoholics. This question has recently been studied by Neumann, who 
considers that his method of ashing the urine allows a very accurate 
estimation of the iron. Neumann and Mayer 42 found that the output 
of a normal person varied from 0.93 to 1.139 mg., an average of 
0.983. In pathological urines they found it increased, especially in 
alcoholics. Their finding concerning diabetes is very interesting, 
since the iron output was parallel to that of the sugar; the ratio 
42 Zeitschr. f. physiol. Chem., 1902, vol. xxxvii. p. 2. 

10 



146 



CLINICAL DIAGNOSIS 



being quite constantly 2.5 mg. per 100 gms. of sugar. They therefore 
suspect that both bodies have a common source. 

Lead. — Considerable urine is evaporated to dryness, and 50 cc. 
of fuming HNOo added; after the reaction subsides it is allowed to 
simmer over the free flame for half an hour, and then 25 cc. more acid 
added three times, each fifteen minutes. The fluid is then evaporated 
to small volume, neutralized with NaOH, filtered, and the lead tested 
with H 2 S, which will give a brown precipitate. 

Arsenic may be tested by saturating the faintly acid urine with 
H 2 S, allowing it to stand from twelve to twenty-four hours, filter- 
ing, washing, and treating the precipitate with bromine water, which 
will dissolve the arsenic sulphide. The solution is placed in a suitable 
flask, to which is added zinc and sulphuric acid, and the stream of 
hydrogen conducted into an acid AgNO >3 solution (AgN0 3 , 0.1 to 
0.2 gm. ; HNO3, 2 gms.; water, 10 cc). If AsH 3 is generated, one 
gets a blackish-brown precipitate of metallic arsenic. 

PIGMENTS OF THE URINE 

The value of the ethereal compounds of sulphuric, glycuronic, and 
other acids has been overestimated, yet they have a certain clinical 
importance. 

Indoxyl sulphate, the chief body, originates in the intestine as 
indol which is formed in the decomposition of proteid. Indol is 
absorbed from the intestine, and in the body is oxidized to indoxyl, 
conjugated with sulphuric acid, and excreted as an alkaline salt. In 
men its output is greater on a flesh than on a vegetable diet. In the 
case of fasting persons it arises from the decomposition of the in- 
testinal secretions. There is none in the urine of the new-born or until 
the child is fed cow's milk. In adults a certain amount is always 
present, from 5 to 25 mg. in twenty-four hours on a mixed diet; 
hence only a great increase is of value, and this may reach from 50 
to 150 mg. 

In general, it is increased by the rapid decomposition of albumin 
either in the intestine or elsewhere in the body. The increase in cases 
with limited peristalsis — e.g., peritonitis and ileus — is of importance 
only to indicate the location of the obstruction or of the paralysis of 
the bowel. If the obstruction is in the small intestine, there is a great 
and rapid increase; if in the colon, either there is no increase or one 
beginning late. Its formation seems to depend upon the presence of 
trypsin, which before it reaches the colon has been either destroyed 
or reabsorbed. It cannot be used to distinguish peritonitis from a 
twist of the bowel. In one very interesting case of syphilitic stricture 
of the ileum the obstruction, which occurred frequently, due evidently 
to the accumulation of fecal matter above the constriction, could be 



THE UKINE: PIGMENTS 



147 



foretold by the increase of this body, which reached a high point and 
then, as the food gradually passed on, cleared up much. It is much 
increased in intussusception, new growths, and twists of the small 
intestine. It is increased by intestinal putrefaction, such as occurs in 
diarrhoea, especially the cholera infantum of children, in typhoid 
fever, dilated stomach, and some cases of nephritis. In these condi- 
tions brisk purging diminishes the output greatly. 

It is increased by decomposition of albumin elsewhere in the body, 
as, for instance, in gangrene of the lung tissue, gangrenous empyema, 
putrid bronchitis, in which case it may be very large in amount, 
advanced pulmonary tuberculosis, and advanced intestinal tuberculosis. 
Coriat considers its increase one element of the symptom-complex of 
akinetic mental conditions, and its diminution one element of that of 
the hyperkinetic states. He considers this not due to any intestinal 
condition nor to the diet. In certain cases of chronic constipation it 
is present in large quantities. One such case, a colleague of mine, 
furnished my classes for several years with specimens of urine rich in 
this pigment. This person enjoyed the best of health. He gives a 
history of some severe abdominal condition when ten years of age, 
since which time he has been troubled with constipation. 

His urine on one day was as follows : 

Total amount, 1770 cc., clear yellow color. On boiling, it becomes dark 
brownish-red, almost black, with a dark magenta foam. 

Total S0 3 , 1.59 gms. ; ethereal sulphates, only 14 per cent.! Total sulphur, 
1.82 gms. (as SOs) in twenty-four hours. 

The urine gives a splendid indigo-blue test, not the Rosenbach test. 

It will be seen that despite the color on boiling and the good indoxyl test, 
the ethereal sulphates were not increased. 

The output is diminished by closure of the pancreatic duct, but 
this closure cannot be diagnosed from the absence of indoxyl sulphate 
unless other factors which would favor its formation are present. A 
former idea was that it is increased in conditions of inanition and 
tuberculosis, and there is a long list of diseases in which it has been 
found in abundance, namely, various intestinal troubles, cancers of the 
liver, stomach, or uterus, and lead colic. In cases of peritonitis or of 
appendicitis with abscess, an increase of inclican is an unfavorable 
sign; its decrease, a favorable one. It is increased when the HQ 
of the gastric juice is diminished. It seems to bear some relation to 
the albumin output, and the insurance companies are beginning to 
consider it an early feature of nephritis. This opinion, however, needs 
confirmation. 

Phenol is almost always increased with it ; the reverse, however, 
is not true. 

The urine when voided is, as a rule, normal in color. In certain 
cases the oxidation occurs within the body and the urine is green 



148 



CLINICAL DIAGNOSIS 



when voided (the blue of the indigo plus the yellow of the urine). 
Such cases are described by Sahli, MacPhedran and Goldie, and others, 
but are excessively rare, and methylene blue is always to be excluded 
(see page 102). 

Indigo calculi have been found. 

The demonstration of indoxyl depends on its oxidation to indigo- 
blue, and the index of amount is the amount of indigo thus formed. 
2C 8 H 6 NKS0 4 + 0 2 = 2C 8 H 5 NO + 2KHS0 4 

This reaction occurs if an oxidizing agent be added ; also when the 
urine decomposes, in which case it is present as a copper-red scum with 
a metallic glistening. Rarely, however, is there sufficient to be seen 
grossly. 

Indigo-blue is a dark blue powder, insoluble in water, slightly so in chloro- 
form, easily soluble in hot aniline. It is insoluble in alcohol and ether. It 
should be collected on an asbestos filter, washed with water, then with alcohol (to 
separate the indigo-red), and then dried. 

Tests : It may be sublimed at 300 0 C, giving off a purple-red vapor which 
cools in prismatic crystals of a copper-red metallic color, deep blue on transmitted 
light. If indigo-blue be mixed with hot alcohol, very strong NaOH, and some glu- 
cose, the whole filling a closed flask, indigo-white is formed. If then exposed to 
the air, indigo-blue will recrystallize out. 

Tests of Indoxyl Sulphate. Jaife's Test. — A test-tube is half 
filled with urine, another of the same size with the same amount of con- 
centrated HC1. On the edge of this latter test-tube is placed the small- 
est drop of fresh concentrated Ca(C10) 2 . The HQ is then poured 
quftkly into the urine, carrying with it this drop as it flows over the 
edge. The fluids are mixed rapidly by invertijjy^not by shaking the 
tube. One cubic centimetre or so of chloroform Ti' then added, which 
will extract the indigo as it is formed. If necessary then another drop 
or two of the Ca(C10) 2 solution may be added. The test may be 
performed as a contact test. Hammersten advises that to 20 cc. of 
urine 2 or 3 cc. of chloroform be added, and an equal amount of hydro- 
chloric acid; then at once Ca(C10) 2 drop by drop, reversing the tube 
several times after each addition. The difficulty with this test is that 
a slight excess of the hypochlorite will destroy the indigo, giving 
yellow isatin. Albumin must be first removed by boiling and filtering. 

Ca(C10) 2 is a difficult substance to obtain pure, since it deteriorates so rapidly 
that the manufacturing chemists refuse to import it. A pure salt, however, is 
unnecessary, the ordinary cheap bleaching powder or " chloride of lime" being 
satisfactory. (Chloride of lime, it should be remembered, is not calcium chloride, 
but a mixture of calcium hydroxide, calcium chloride, and calcium hypochlorite). 

Obermayer's Test. — The urine is first precipitated with about 
one-fifth volume of 20 per cent. PbAc, avoiding an excess, then filtered. 
Disturbing substances are thus removed. An equal amount of fuming 



THE HEINE: PIGMENTS 



149 



hydrochloric acid containing Fe 2 Cl 6 is then added (4 parts of Fe 2 Cl 0( 
in 1 litre of HC1). In a few minutes the reaction is apparent, and 
the indigo can be extracted with chloroform. 

If potassium iodide is in the urine, a violet color is obtained. With thymol 
the urine becomes bluish-green. 

Aman's reaction with Na^Oz has been found of doubtful value. 

The test may also be performed by adding 30 drops of urine to 15 cc. of HC1, 
plus 1 or 2 drops of HNO s . The mixture is stirred at once, and amethyst color 
results, which reaches a maximum in from five to thirty minutes. 

Since nitric acid gives the test, indol may disturb a bile test. In case the 
urine looks grossly as if indigo were present (the color of such a urine will be 
blackish-green or bluish), the indigo may be extracted with acidulated chloroform. 

Indigo will crystallize out in needles or plates if evaporated from chloroform. 

Quantitative Determinations. — These are in general unsatis- 
factory, the gross estimate by the color, using the Obermayer reagent, 
being usually sufficient. This urine may be repeatedly extracted, the 
extracts evaporated in a weighed beaker. The indigo-red may in 
this case be removed by washing with alcohol. It is dried at 105 0 to 
no° C. and weighed. 

Ellinger 43 found that but 85 per cent, of the theoretical amount was in this 
way obtained (evidently isatin is formed), and that neither the concentration 
nor the excess of reagent was of moment if one quickly extracted the indigo-blue. 
The urine is, if necessary, made slightly acid with acetic acid, precipitated with 
one-tenth volume of PbAc and, if concentrated, diluted one-half. To a measured 
portion of the filtrate is then added an equal volume of Obermayer's reagent, and 
shaken out several times with chloroform until this is no longer colored. The 
amount of filtrate chosen should be such that three to four extractions with 30 cc. 
of chloroform, for two minutes each time, is enough. The filtered extract is 
distilled, the extract dried for five minutes, then washed out two to three times 
with hot water (to remove isatin), dissolved in 10 cc. of concentrated H2SO4, 
this solution diluted to 100 cc. with water, and titrated with a dilute KMnCX solu- 
tion (5 cc. of a 0.3 per cent, solution diluted to 200 cc.) which has been standardized 
with pure indigo-blue. About 87 per cent, of the correct amount is found, hence 
the result may be increased by one-sixth. A double determination requires about 
one and a half hours. 

Strauss 44 also uses Obermayer's solution and extracts with chloroform. He 
uses a small separating funnel similar to that for lactic acid (see Fig. 63). The 
combined chloroform extracts are measured, 2 cc. removed and diluted till its 
color matches that of a standard tube of known content, and from this he reckons 
the total amount. 

Bouma's method 45 has received severe criticism. 

Coriat proposes 46 a graduated separating funnel, in which the Ca(C10) 2 test is 
made and the chloroform extract compared with a standard color. 

Skatoxyl-sulphate. — Skatol is also formed in the intestine, the result of 
the bacterial decomposition of albumin, and is absorbed. By analogy we may 
suppose it to be oxidized to skatoxyl, conjugated with sulphuric acid, and elimi- 
nated by the urine. As a matter of fact, however, the skatoxyl sulphuric acid 
has seldom, if ever, been actually demonstrated in the urine, and the colors which 
would indicate it may be as well due to other red pigments. 

43 Zeitschr. f. physiol. Chem., vol. xxxviii. p. 178. 

44 Deutsche med. Wochenschr., April 17, 1902. 

45 Zeitschr. f. physiol. Chem., 1901, vol. xxxii. p. 82. 

46 Am. Jour. Med. Sci., April, 1902. 



150 



CLINICAL DIAGNOSIS 



Stokvis 47 has given a method for the separation of the chromogens of these 
blue and red pigments. The urine is saturated with (NH^SCX, allowed to stand 
till all pigments are precipitated, filtered, the filtrate evaporated on the water-bath, 
and the fluid decanted from the crystals of (NH 4 ) 2 S04. It is then acidified with 
a few drops of acetic acid, and shaken out with an equal volume of acetic ether, 
which takes up both chromogens to a yellow solution. To the acetic ether is now 
added water several times to separate out the chromogen of indigo-blue. It is 
then neutralized with dilute KOH and shaken out, the dilute KOH separating the 
chromogen of skatol-red, which can be tested with Obermayer's solution. 

The red or violet color produced by adding an oxidizing agent with a strong 
acid to the urine is usually attributed to this body. With Fe 2 Clo it does give a violet 
color, with concentrated HNOs a cherry-red color, with concentrated HC1 it is 
decomposed with a red precipitate. In Jaffe's test the urine is dark red or violet. 
On standing in the air the urine becomes darker from above downward, — of a 
red, violet, or even black color. As has already been mentioned, these colors are 
not conclusive. Rosin denies that it has ever been found, and thinks all of these 
tests could be explained by indigo-red. Its demonstration would necessitate the 
reduction of the pigment by zinc-dust with skatol as the product. 

Indigo-red. — Other names for this pigment are many, urorubin 
and urorhodin being among them. * This body is always formed with 
indigo-blue, especially by Jaffe's test with the warm urine. They are 
isomeres and arise from the same mother substance (indoxyl sul- 
phate). It is also formed in decomposing urine and may form a sedi- 
ment. Urorosein is formed at the same time. 

Indigo-red crystallizes in dark reddish-brown or chocolate-brown needles or 
plates. It sublimes with violet-red fumes at 295 0 to 310 0 C. It is insoluble 
in water, dilute acids, and alkalies. It gives a cherry-red solution with alcohol, 
ether, chloroform, and especially glacial acetic acid. From dilute alcohol solution 
it precipitates in crystals. From glacial acetic acid it is precipitated by soda or by 
water. It gives a characteristic absorption spectrum. 

Reduction Test. — The alcohol solution is made alkaline with sodium carbon- 
ate, a little glucose added, and gently warmed. The solution is decolorized, but 
the color returns on shaking it in the air. This can be repeated as often as 
desired. If the pigment be boiled with caustic alkali, even dilute, the red is 
destroyed and various brown decomposition products formed. 

This pigment is present in large amounts in certain urines which 
give Rosenbach's test, but it alone is not responsible for the Burgundy- 
red color. It is increased especially in intestinal troubles, — ileus, 
obstruction, cancer, etc. It is also present in large amounts in some 
urines which do not give a characteristic Rosenbach test, but these 
conditions are so various that they cannot be classified. It may also 
be found in traces in normal urine. 

Demonstration. — Nitric acid is the best reagent, its addition giving a red 
color. Much is formed by Jaffe's test, especially if the urine be heated. When 
cold, the urine may be neutralized with soda, then shaken out with ether. The 
ether takes a fine red color and gives the absorption spectrum of this body. The 
ether extract may be evaporated in a watch-glass to obtain crystals. 

Indigo-red is present in certain freshly voided urines as in cases of pyelocys- 
titis. It has also been found in concretions. 

47 Centr. f. inn. Med., 1902, No. 28. 



THE YPtIXE: CHOLUKIA 



153 



Among other red pigments of the urine is urorosein. This is 
characterized by its easy solubility in amyl alcohol, its insolubility in 
chloroform, ether, and benzol. Ammonia and alkaline carbonates de- 
colorize it at once ; acid restores the color. It may be recognized from 
its spectrum. It is very unstable and decomposes rapidly. It occurs 
in normal urine. 

To demonstrate it one-tenth volume of HC1 is added, and then the fluid is 
filtered. The red stain which remains on the filter is urorosein. Urorosein is 
produced by JafTe's test, but is not extracted by the chloroform or ether. Other 
red pigments may be demonstrated in the urine, and after boiling it with acid 
various brown pigments with which it is tempting to work but not very profitable. 
These pigments, somewhat similar in appearance but different in their solubilities, 
will puzzle one considerably. 

Paracresol and Phenolsulphuric Acid. — Phenol is present in the 
urine, from 17 to 51 mg. per twenty- four hours. The amount of these 
two bodies, however, of which the former usually exceeds in amount, 
varies in various conditions. It is increased with a vegetable diet. In 
ileus and peritonitis much phenol is present, also in diphtheria, scarlet 
fever, erysipelas ; but little in typhoid fever, smallpox, and meningitis. 
They are formed from decomposition in any part of the body and 
when the intestinal decomposition is much increased. Their occur- 
rence is thus much the same as indoxylsulphuric acid, the phenol in- 
creasing with this, but the reverse is not always the case. 

Pyrocatechin (see pageioi)is another body conjugated with sul- 
phuric acid, and 

Hydrochinon (see page 101) also, especially after carbolic acid 
poisoning. 

Potassium Iodide is often found in the urine when making the tests 
for pigments. If HN0 3 be added, and then chloroform, the latter will 
take the pink color of iodine. Or powdered starch may be added after 
the HNO3, an d the starch iodine blue will be very distinct. 

BILE PIGMENTS 

The Clinical Occurrence of Bile Pigments in the Urine. — Bile pig- 
ment never occurs in the human urine normally, although it is a con- 
stituent of the normal urine of some animals. Its origin is the blood 
pigment, as may be seen by the fact that it is increased and the inter- 
mediate stages occur in the plasma, when there is increased breaking 
down of red blood-cells, — e.g., in haemoglobinsemia, after a blood 
poison. It is very similar to hsematin, and is an isomer of hsemato- 
porphyrin. In cholsemia it is thought that the most of the bilirubin 
is reduced by the kidneys to the more diffusible urobilin. 

The cases of jaundice have been divided into two groups, — the 
f- hepatogenous," due to obstruction of bile passages, in which case bile 



152 



CLINICAL DIAGNOSIS 



is present in the urine sooner or later, as in cases of catarrhal jaundice, 
jaundice due to calculus, cancer or cirrhosis of the liver ; and the 
" hematogenous," formerly supposed to be due to destruction of the 
red blood-corpuscles by poisons, as phosphorus or the toxines of severe 
infections, in which cases bile may appear in the urine before the 
skin or conjunctivae are stained. The previous idea was that in these 
latter cases the liver could not warehouse all of the free haemoglobin, 
and hence some was excreted as bilirubin. More recently such jaun- 
dice has been doubted (Stadelmann) . and all cases are supposed to be 
hepatogenous in origin ; that is, the increased bile pigment is reab- 
sorbed in the liver, since it is perhaps too viscid to flow well through 
the bile ducts, or there is too little pressure from behind, or perhaps 
there is closure of the smallest ducts from swelling of the cells. 
" Toxemic jaundice" has been proposed as a better term. 

The bile pigments, and their derivatives of interest in clinical chem- 
istry, are bilirubin, biliverdin, bilifuscin, biliprasin, cholecyanin, and 
choletelin, all of which are products of bilirubin, and many of which 
are seen in the play of colors of the Gmelin test. The first two, bili- 
rubin and biliverdin, are the only ones of much importance except in 
explaining the colors in tests. Bilirubin alone has been proved in fresh 
urine. Biliverdin often occurs, but, as a rule, only after the urine has 
stood for even a short time, in which case it is the effect of oxidization 
by bacterial action. These pigments are always present in the urine 
in cases of jaundice of much intensity. It should be remembered, 
however, that all of the pigment may be in the urate sediment. 

Bilirubin, C 32 H 36 N 4 0 6 . — This is the pigment which occurs free in 
the bile of man. Its calcium salts occur in gall-stones, its crystals occur 
in old blood extravasations, the so-called haematoidin crystals supposed 
formerly to be a different substance but now generally admitted to be 
the same. It is probable that bilirubin can arise elsewhere than in the 
liver. It occurs in the fluid of certain cysts, especially of the breast 
and of the thyroid. 

This pigment may be isolated from fluids containing other pigments by pre- 
cipitating with the milk of lime in moderate amount, shaking well. C0 2 is led in 
at once to prevent the decomposition of methaemoglobin et ad., and the mixture 
filtered. The precipitate is washed, and dissolved in alcohol ; chloroform is 
then added, and then acetic acid, to separate out the calcium. This is filtered, 
the chloroform separated by adding water, and the chloroform extract is filtered 
through a dry paper and evaporated. The bilirubin of the residue is washed with 
a little alcohol and ether. The results 03^ this method are always a little too low, 
since calcium does not precipitate all the pigment and some is later destroyed. 
The work must be done rapidly. Haematin, if present, would also be isolated, but 
hsematin does not occur in the body, except perhaps in the stomach and intestinal 
contents. 

The crystals are rhombs often with rounded edges, or needles, if 
pure of a beautiful brown-red color. It is perfectly insoluble in water, 



THE TJKINE: CHOLUEIA 



153 



is soluble in alcohol and in chloroform, especially if hot, these solu- 
tions having a brownish-red color. It is precipitated unchanged 
from alcoholic solution by acids, forms compounds with alkalies, 
these compounds being insoluble in chloroform but soluble in 
water; hence bilirubin may be washed from a chloroform solution by 
an alkali. In this it differs from lutein. It is precipitated by BaS0 4 
and (NH 4 ) 2 S0 4 . The alkaline solution exposed to the air turns to 
the green biliverdin. In the alkaline urine, however, this is not always 
the case, since one product of the decomposition of urine is (NH 4 ) 2 S, 
which changes biliverdin and bilicyanin to bilirubin, and the bilirubin 
itself may disappear from an alkaline urine, also from a urine pre-, 
served with chloroform. Bilirubin has no absorption spectrum. 

Biliverdin, C 32 H 36 N 4 0 8 , occurs in the bile of many animals, but 
not of men. It occurs, however, in the intestine and vomitus, and in 
jaundiced urine after standing even for a short time. When pure it 
is an amorphous, greenish-black pow;der, insoluble in water, ether, or 
chloroform, but easily soluble in alcohol. Its compounds with the alka- 
lies are soluble to a green or a brownish-green solution. It is soluble 
in concentrated acetic acid and in HC1. The alkaline solution has no 
absorption spectrum, but an alcoholic weakly acid solution shows one 
band. With Gmelin's test it gives the same color changes as bilirubin, 
from which it differs in its color, solubility in alcohol, and insolubility 
in chloroform. It may be reduced to bilirubin. 

Hydrobilirubin, C 32 H 46 N 2 0 7 , is considered by some to be the same 
as urobilin, but this is denied by the majority. This occurs in the 
lower intestine as a reduced product of bilirubin by bacteria. 

Bilifuscin is a body not yet isolated pure. That described (C32H10N4OS) is of 
an amorphous brown color, soluble in alcohol to a deep brown solution, and in 
alkali, ammonia, and dilute NaOH. It is insoluble in water and ether, and nearly 
soluble in chloroform. It is soluble in ether and chlorpform if fatty acids be pres- 
ent. In the pure state it does not give Gmelin reaction ; its spectrum is similar to 
that of biliprasin. 

Biliprasin is commonly said to be a mixture of bilirubin and bilifuscin. By 
others it is said to be an intermediate stage between bilirubin and biliverdin. 
Others consider it identical with biliverdin. The formula given is C32H44N4O12. 
The alcoholic solution has no absorption spectrum, while the alkaline solution 
has. The color of its alcoholic alkaline solution is brown, the chief difference 1 
between this and biliverdin. It differs from bilifuscin, since if acid be added to 
this solution, the color changes to green. The Gmelin test is of no value in recog- 
nizing this pigment. 

Of the above pigments, the spectrum analysis is unsatisfactory for their recog- 
nition. It is the products of their oxidation which are easily recognized by this 
method. 

Cholecyanin. — This is an oxidized product of the bile pigments with nitric 
acid, PbO, or KMn0 4 . It gives a characteristic spectrum, and may be further 
oxidized to choletelin. Cholecyanin is insoluble in H 2 0, soluble in alkalies and 
strong acids. It may be reduced to bilirubin. The neutral or faintly acid solution 
is of a bluish-green or steel-blue color with a beautiful red fluorescence. The 



154 



CLINICAL DIAGNOSIS 



alkaline solution is of a green color. The only way of recognizing it is by its 
beautiful spectrum. 

Choletelin. — Choletelin may be produced by the oxidation of bilirubin with 
HN0 3 . It is soluble in alcohol giving a ruby-red color. The dilute solution is a 
yellowish-red, and does not change in color with the change of reaction, as is the 
case of urobilin. It does not fluoresce. Chemically it is similar to urobilin, but its 
absorption spectrum differs, and with ZnCL it gives no fluorescence. It is not 
precipitated by PbAc. In testing the spectrum the solution must be made acid with 
acetic acid, and the lines for urobilin must not be mistaken. The spectrum is the 
only means of recognition. 

The reducible body of Stokvis is a by-product of the complete oxidation of 
bile pigment. It is a substance soluble in water, alcohol, alkali, and dilute acid, 
but not in ether or chloroform. It is not precipitated by PbAc, but is by PbAc 
and NH4OH. It is characterized by the fact that if its alkaline solution be 
boiled with a reducing substance (e.g., (NH^S), the solution becomes a beau- 
tiful rose-red with an absorption spectrum. This shaken with air, the rose red 
disappears, and it is restored to its original color with the disappearance of the 
spectrum. 

The color of the urine does not depend alone on the amount of bili- 
rubin present, for much may be present in a pale urine and little in a 
very dark. In general it varies from a dark yellow to brown or even 
greenish-black. The most characteristic feature is the yellow foam, 
since in a very dark non- jaundiced urine the foam produced by shaking 
is pure white unless much urobilin be present. The urine has a yellow 
sediment and stains the filter paper yellow. As a rule, in such urine 
there is also an excess of urobilin and indoxyl, hence when the bilirubin 
disappears the color of the urine still remains dark. It also contains 
the nucleo-albumin of the bile. Such urines are not adapted to Heller's 
albumin test since the oxidized pigment will confuse one. 

Tests. — If there be much bile in the urine it may be shaken out with 
chloroform, the chloroform extract poured off, evaporated, the residue 
taken up again with chloroform, and evaporated in a watch-glass. 
Rhombic prisms of bilirubin are seen which are soluble in alkali, give 
the Gmelin test, and on exposure to the air become green. 

Gmelin's Test. — The urine is superimposed in a test-tube on 
crude HN0 3 (sp. gr. at least 1.4). The urine is best added with a 
pipette and these fluids stratified as for the albumin test. The HN0 3 
should be faintly yellow with HNOo, not too much nor too little so. 
The yellow may be increased by adding a few pine shavings to the 
nitric acid or diminished by adding a little urea. 

If bilirubin be present, strata of colors will be seen in the urine 
which from above downward are green, blue, violet, red, and, just 
above the HN0 3 , yellow. 

If too much HNO2 be present, soon the whole is yellow. This test cannot be 
applied to a very dark urine or to a urine rich in indican. If the latter be present, 
the blue of indigo may with the yellow of the urine give a deceptive green. The 
ring has a black tone, and a fine precipitate can be seen. If in doubt the urine 
may be extracted with chloroform and both pigments tested for. A violet-red ring 
may be due to skatoxyl. Often only a green color is seen. This is necessary for 



THE URINE: CH0LUEIA 



155 



diagnosis, and most persons agree is sufficient. The violet-red, according to others, 
must also be present, else the test may be confused with that of lutein, which 
gives a blue or a bluish-green ring ; but in the case of urine this pigment will 
not disturb. The violet-red is due to skatol and indoxyl. Biliverdin also gives 
this test, but the reaction occurs in a shorter time since the first oxidation step 
is already present. The test may fail if too much HNO2 be in the nitric acid, since 
the green will not be seen. 

Alcoholic solutions cannot be tested, since alcohol alone will give this test. 
If urines are shaken out with ether, the ether must be alcohol-free, and this is not 
always the case. 

If urobilin be abundant, the bile test will be poor, but, as a rule, it does not 
disturb much. The urine should be diluted to a specific gravity of 1005, and the 
green bile test obtained. Some prefer always to dilute, since then only the green 
is seen. 

Lutein of the serum does not disturb, but methaemoglobin may. An abundant 
albumin precipitate will obscure the test, and if the albumin be removed it will 
carry the bile down with it. This albumin precipitate should be dried and ex- 
tracted with chloroform. A trace of albumin will not disturb the test, and if much 
bile be present will even improve it, since so much will be carried down with the 
precipitate, but if only a trace of bile be present and a trace of albumin, the latter 
must be precipitated, dried, and extracted. . ■ 

The Gmelin test is said to indicate as little as 1 : 80,000. 

After the ingestion of antipyrin it is said that the test is positive. 

Rosenbach's test is the best modification of Gmelin's test, being 
the most sensitive. Much urine is filtered several times through a filter 
paper, which will retain the bile-stained elements of the sediment. The 
filter is then partially dried with dry filter paper and one drop of yel- 
low HNO a dropped upon it. Rings will be seen which will present 
the above-mentioned play of colors, the external one being green. The 
urine should be somewhat acidified with HC1 before filtering. If the 
paper be allowed to dry, it should be again moistened with water be- 
fore the test. Instead of filter paper Dragendorff uses a porous porce- 
lain plate. 

A test considered by some very delicate is the following. A test-tube is filled 
full of urine, and 2 cc. of chloroform and 3 drops of HC1 added. It is then 
thoroughly mixed. The bile pigment, which acts as an acid, is set free from its 
alkali combination by the HQ, and, being more soluble in this condition in chloro- 
form than water, is extracted by the chloroform, the free pigment being insoluble 
in water. The chloroform is then poured off into another test-tube and equal 
amounts of water added. One drop of NaOH is then added, transforming the free 
pigment to an alkali salt, which is again soluble in water. The H2O solution is 
then tested with nitric acid, or the chloroform extract may be evaporated in a 
watch-glass and the crystals studied. 

By another method the urine is rendered alkaline with NaOH, or soda, and 
precipitated as long as a colored precipitate falls with BaCl 2 or CaCl 2 , or the 
hydroxides of these metals. The yellow precipitate is then filtered off and boiled 
with alcohol plus a few drops of dilute H2SO4. A beautiful clear green solution 
is obtained. If no pigment is present it is colorless ; if chrysophanic acid is present, 
orange-yellow. This test is po'sitive when other tests are negative. 

The bilirubin may also be extracted with chloroform from acid urine (add a 
few drops of HQ). An emulsion should be avoided, however, by not shaking too 
vigorously. In caseyt be necessary to test t^e urate sediment/ a^nd this may contain 



156 



CLINICAL DIAGNOSIS 



all of the bile in the urine, the sediment is dissolved with soda and the solution 
tested for bilirubin. 

Hammarsten's Test. — An acid mixture is used, consisting of i part 25 per 
cent. HNOs and 19 parts of 25 per cent. HO. This reagent is allowed to stand 
until yellow. To 1 part of this are added 4 of alcohol ; this mixture is made 
fresh before each test. To a few cubic centimetres of this fluid are then added 
a few drops of a bilirubin solution. At once is obtained a permanent beautiful 
green color. If more acid be added we get at will the other colors, even the yellow 
choletelin. But for urine this test. must be modified somewhat. Ten cc. of urine 
are placed in a 15 cc. tube of a centrifuge, a few cubic centimetres of BaCL> solu- 
tion added and the mixture centrifugalized for from one-half to one minute. The 
supernatant fluid is then poured off. 1.2 cc. of the above acid reagent are then 
added to the sediment, this shaken well and centrifugalized for half a minute. (If 
CaGU be used, this last centrifugalization is not necessary.) A green solution is 
obtained. The test is very delicate, being positive if there is 1 part of the pigment 
in 500,000 to 1,000,000 parts of urine. 

Huppert's Test. — Ten cc. of urine are made alkaline with soda 
and CaCl 2 added as long as a precipitate is formed. This is filtered 
in a small filter and washed with water. The filter with the precipitate 
is then placed in a porcelain dish and acid alcohol (5 cc. HC1 in 100 cc. 
of alcohol) added. This is heated and gives a green to a blue colored 
solution. This test is advised should indican be abundant or the urine 
dark in color. 

Nakayama's Modification of Huppert's Test. — The reagent 
used consists of 95 per cent, alcohol, 99 parts ; fuming HQ, 1 part; and 
4 gms. Fe 2 Cl 6 per litre of the above mixture. To 5 cc. of acid urine 
are added an equal amount of 10 per cent. BaCl 2 solution and centrifu- 
galized. The supernatant clear fluid is poured off, to the precipitate 
are added 2 cc. of the above reagent, and the fluid is then heated to a 
boil. A green solution is obtained, or a bluish green, which on the 
addition of yellow HN0 3 becomes violet or red. The test is said to be 
positive for 1 part of bilirubin in 1,200,000 parts of urine; that is, it is 
almost twice as delicate as Huppert's test. 

The following very important test or modifications of it has gone 
under four different names, Trousseau's, perhaps, having priority. 
The urine, acidified if necessary with acetic acid, is mixed with a tinct- 
ure of iodine, or a contact test made, the iodine tincture being super- 
imposed upon the urine. A fine emerald-green color is obtained (which 
is not biliverdin but a substitution product of bilirubin with iodine). 
This test is more sensitive than Gmelin's ; it is even more delicate if 
the tincture of iodine be diluted 1:10 with alcohol (hence a 1 per cent, 
iodine solution) and the urine be overlaid with this. A green ring 
appearing at once or in one minute will indicate bile (Rosin). In this 
test there is no confusion with indoxyl. It is said, however, that some 
normal urines will give a positive test. (CI or Br may also be used.) 

Stokvis's Cholecyanin Test. — This test is a good control if bile be present 
with much other pigment, but it is not as delicate as some of the above. To 20 to 



THE FKWE 



157 



30 ce. of urine are added 5 to 10 cc. of ZnAc solution. A little soda is added to 
reduce the acidity. Or, 20 per cent. ZnCl 2 solution may be used. It is then 
filtered. The precipitate contains all of the bile. This is dissolved in NHLOH. The 
bile pigment is now in the form of cholecyanin. The solution is neutralized, is of 
a blue-green color, with a red fluorescence and a characteristic three-band spectrum. 

Many of these tests are good. Some when bile alone is present, 
others in the presence of other pigments also. 

Certain substances may be in the urine which it is important should 
not be mistaken for bile, as after the use of rhubarb, senna, and san- 
tonin. These urines become red on the addition of an alkali, but the 
color is restored if the urine be again acidified. 

Microscopically, it is important to recognize the crystals of bili- 
rubin. They are commonly present in jaundiced urine if concen- 
trated for leucin and tyrosin. The urine is rendered acid with HC1 
and allowed to stand in the cold. Bilirubin will precipitate out in in- 
tensely brown sheaths or rhombs often with rounded edges ; their color 
should prevent any confusion. 

It is sometimes desirable to remove bile from the urine. This 
may be done by extracting a urine acidified with HC1 with chloroform, 
or by briefly boiling with a little animal charcoal. This latter method 
should be carefully used, since other substances, perhaps the one 
sought for, may also be removed. 

KMn0 4 in acid solution destroys the bile pigments perfectly. Two 
drops of HNO3 or HC1 per 1 cc. of urine are added, and 2 drops of 
4 per cent. KMn0 4 . The urine is then warmed and shaken a little. 

Bouma 48 recommends the following quantitative determina- 
tion for bile: To 10 cc. of fresh urine are added 2 cc. of 20 per 
cent. CaCl 2 solution. The urine is then almost neutralized with 
XH 4 OH. The slightly acid urine is then centrifugalized, the fluid is 
poured off, the sediment shaken up with water and centrifugalized 
again to wash the sediment. The fluid is entirely decanted, and 5 cc. 
of a mixture of 4 cc. of absolute alcohol and 1 cc. of Obermayer's 
reagent (1.5 gms. of Fe 2 Cl 6 in 1 litre of HQ, sp. gr. 1.15) are added. 
This is then poured into a test-tube, and compared with a set of six 
standard tubes to match the biliverdin which has been formed. If 
much bilirubin (more than 100 mg. ) be present, the urine is diluted 
with normal urine (thus not diluting the phosphates). 

Melanin-Melanogen. — In the case of melanotic tumors this sub- 
stance or substances (Morner) may be present in the urine. The 
chromogen is colorless, but the urine on standing, or after the addi- 
tion of an alkali or oxidizing agent, turns black, beginning at the 
top ; it may be intensified by adding HN0 3 or Fe 2 Cl fi . It is insoluble 
in chloroform, which prevents its confusion with indoxyl. It may be 

48 Deutsche med. Wochenschr., 1904, No. 24. 



158 



CLINICAL DIAGNOSIS 



present as an amorphous sediment. It is decolorized by boiling with 
NH0 3 . 

Rosenbach's Reaction. — The urine is boiled, adding from time to 
time, drop by drop, strong nitric acid. The urine takes a Burgundy- 
red color and the foam a bluish-red. The foam must be of this color, 
since the red of the urine may be due to urobilin. (An excess of HNO s 
gives a yellowish-red to yellow color with a yellow foam.) If, then, 
soda or ammonia be added drop by drop we get a bluish-red precipitate 
soluble in excess and a brownish-red solution. This test is said to 
be due to indigo-red (Rosin), perhaps also skatoxyl-red. It has the 
same significance as the indoxyl reaction. 

Bile Acids. — Glycocholic and taurocholic acids are denied to be 
constituents of normal urine, as was formerly believed, but they may 
occur in large amounts in jaundice, especially the obstructive, although 
none may be present even here, and in toxic jaundice they appear but 
in traces. Formerly their presence was supposed to speak against 
the latter, but they are of little value in this differential diagnosis. 
Their direct detection in the urine is impossible unless 0.5 per cent, of 
the acid be present. 

Separation. — Thierf 'elder recommends that the urine be concen- 
trated to a small volume, the residue extracted with strong alcohol, 
and filtered. The alcohol is evaporated and the urine precipitated with 
basic PbAc and NH 4 OfI. The precipitate is washed with water, dried, 
treated with boiling alcohol several times, and filtered hot. The filtrate, 
plus a few drops of soda solution to decompose the Pb salts, is 
evaporated to dryness, the residue extracted with absolute alcohol, 
filtered, and a great excess of ether added and allowed to stand. An 
amorphous precipitate of the sodium salts of these acids is obtained, 
later crystalline. The precipitate is dissolved in water and tested by 
Pettinkofer's test. 

Tyson Method. — From 180 to 240 cc. of urine are evaporated to 
dryness on the water-bath. An excess of absolute alcohol is added 
to the residue and filtered. To the filtrate are added from 12 to 
14 volumes of ether, which precipitates the bile acids. They are then 
filtered off, dissolved in distilled water, and decolorized with animal 
charcoal. 

Pettinkofer's Reaction. — To the solution in a test-tube is added a 
little cane-sugar and then slowly drop by drop concentrated H 2 S0 4 , 
shaking well all the time and warming to 70 0 C, not over, and cooling 
if necessary. We get first a precipitate of cholic acid, which redis- 
solves. Then when more H 2 S0 4 is added there is obtained, first a 
cherry- red, then a beautiful purple color, which in eight days is a 
bluish-red. This color is due to the reaction of cholic acid and the 
furfurol, which is formed by the action of sulphuric acid on cane- 



THE URINE: DIAZO TEST 



J 59 



sugar. The purple-red solution may be diluted with alcohol, and 
shows a characteristic absorption spectrum. Confusing substances 
which may be present are albuminous bodies, many bodies easily de- 
composed by H 2 S0 4 , many pigments, amyl alcohol, and oleic acid; 
but in all these the absorption spectrum fails. 

Udranzky's Test. — This is the best test. Furfurol is used directly. 
To i cc. of the solution to be tested is added i drop of a o.i per cent, 
watery furfurol solution. This is underlaid with I cc. of concentrated 
H 2 S0 4 and cooled to restrain the reaction. In the presence of only 
0.033 m S- °f cholic acid is obtained a red color which after standing 
becomes a blood-red. If 0.05 mg. be present, one gets a distinct 
absorption line in the spectrum. The spectrum must always be ex- 
amined for confirmation. A 10 per cent, cane-sugar solution will give 
as good a test as a o. 1 per cent, furfurol solution. The red color must 
have a clearly bluish tinge. 

If the cane-sugar be used in excess it is burned to a brown or a black. An 
excess of furfurol gives an orange color. Oxidizing bodies prevent the reaction. 

Strassburger's test may be sometimes applied directly to the urine. It is use- 
less, however, since normal urine will give a confusing color, and jaundiced urine 
is not suitable because of its color. This test is easy if a little bile be added to 
normal urine, but it is almost impossible to apply in a jaundiced urine. To the 
urine was added a little cane-sugar and then filtered ; the filter paper was dried, 
and one drop of pure sulphuric acid added. In about a quarter of a minute is 
seen a violet spot. This will detect 0.3 gm. in 1 litre. 

Skatoxyl and indoxyl will give a violet color, and with concentrated normal 
urine beautiful positive tests may be obtained. 

If one wishes to be sure of bile acids they must be isolated as lead salts, the 
other tests being unsatisfactory. 

Hay's test for bile acids is said to be very easy, sensitive, and accu- 
rate, being given by no other body occurring in the urine, and more 
delicate than the Pettinkofer test. On the surface of the urine (which 
has been cooled, if necessary, to a temperature not higher than 17 0 C.) 
is sprinkled a little finely powdered sulphur. If the sulphur sinks at 
once, it indicates 1 : 10,000. If it sinks after shaking gently and 
waiting one minute, 1 : 40,000. It is given by even 1 : 120,000. The 
bile salts are said to lower the surface tension. 49 

Diazo Test. — Certain diazo bodies combined with aromatic com- 
pounds give a colored reaction. A test depending on this is recom- 
mended by Ehrlich for clinical use. What body or bodies give it in 
the urine are unknown, but the empirical value of the test is granted. 
Since there are a great many diazo tests for various bodies, one must 
be careful in modifying this one of Ehrlich. 

Fluids : 

(1) One-half per cent. NaN0 2 . This should be quite fresh. 

^Beddard and Pembrey, Brit. Med. Jour., March 22, 1902. 



160 



CLINICAL DIAGNOSIS 



(2) Five parts of sulphanilic acid, 50 of HQ, 1000 of distilled 
water. 

To 250 cc. of the second are added 5 cc. of the first solution. Only 
a fresh mixture (not over one day old) should be used. Equal parts 
of the urine and this mixed reagent are shaken together until con- 
siderable foam is produced and ammonia is then quickly added in 
excess ; usually it is added drop by drop, although we are warned not 
to thus modify in the least the original technic. If the test be posi- 
tive, the urine will take an intense red, the foam a more or less bril- 
liant rose-red color. A brown color is often obtained in normal 
urines, and unless the color is a definite rose the test should be con- 
sidered negative; a salmon tint is not positive. If a positive test be 
allowed to stand, a precipitate should form, on the upper surface of 
which is a zone of dark greenish-black, or violet. In case the color 
of the foam is doubtful, — if, for instance, after shaking the red 
disappears, — we are recommended to wait twenty-four hours for this 
precipitate. Others consider that the sediment is a less delicate indi- 
cator than is the color of the foam, and is not essential to a positive 
test, hence neglect it. 

Some say the red color must remain in the fluid until the foam is 
gone. 

In Green's modification 100 parts of solution 2 are used with 1 
part of the nitrite. This renders the test more delicate, since fewer 
unexpected positive results are obtained. With strong enough reagents 
every urine will react positively. 

Sulphanilic acid is usually used for the reagent, and yet Zunz pre- 
fers the paramido-acetophenol of Friedenwald's formula : 50 

Paramido-acetophenol, 50 gms. 
Cone. HC1, 50 cc. 
Water, q. s. ad 1000 cc. 

Four drops of a 0.5 per cent, solution NaN0 2 are added to 10 cc. 
of the above solution, and this to 10 cc. of urine. The mixture is then 
shaken, about 3 cc. of ammonia added, and the color of the foam 
observed. It is more delicate and intense than the sulphanilic acid. 
This author prefers to add the ammonia all at once, and not drop 
by drop. He considers the foam as the more important, and the 
precipitate of less value, not sufficient to make the test positive should 
the foam be negative. The disturbing bodies may many of them be 
removed by shaking the urine out with amyl alcohol, which must itself 
be then driven off on the water-bath. 

The test is further modified by Guillemin. Fifty cc. of HQ are 
added to 1 litre of saturated aqueous solution of sulphanilic acid. 
60 New York Med. Jour., 1894, p. 745- 



THE UEINE: DIAZO TEST 



161 



Two and one-half cc. of urine plus an equal amount of this reagent 
are mixed, and then are added two drops of NaN0 2 solution. It is 
then well shaken and from 7 to 10 drops of NH 4 OH added. 

Lamanna makes the solutions with absolute alcohol instead of 
water. 

Solution I. 50 cgms. sulphanilic acid ; 
5 cc. HC1 ; 
100 cc. absolute alcohol ; 
5 cc. glacial acetic acid. 

Solution II. 50 cgms. NaN0 2 ; 

50 cc. absolute alcohol. 

To 5 cc. of urine is then added 1 cc. of NH 4 OH. The reagent 
mixed as in the other tests is then added drop by drop. If the test is 
not positive, a few more drops of the NaN0 2 may be added. 

Several methods of quantitative determination have been at- 
tempted. Konig places in a burette 25 cc. of filtered urine plus 5 cc. 
of NH 4 OH. In a second burette is a mixture of 50 cc. of the sul- 
phanilic acid solution and 1 cc. of NaN0 2 solution. Into a flask 
are measured 5 cc. of the urine solution, and then from the other 
burette the mixture is added drop by drop until a red color appears 
in the foam and fluid which just persists after shaking. — Nizzoli de- 
termines it quantitatively by diluting the urine until the test is just 
positive. This is the method preferred by Zunz, who considers, how- 
ever, that the determination takes more time than it is worth. 

The urine soon loses its property of giving a positive test, but after 
a few days of ammoniacal fermentation the test reappears. 

If necessary to keep the urine several days before testing it, ether 
may be added. 

Some prefer to concentrate the urine on a water-bath to a syrup 
(Michaelis) and get a positive test in some cases in which the urine 
gave none. Zunz has clone the most of his careful work with such 
concentrated urines. That this does not always help matters has been 
shown by ImhofI, who found in the experimental tuberculosis of 
rabbits that the concentrated urine may give a brown foam, but if 
diluted to its previous volume the foam becomes a brilliant red. In 
the case of the human urine similar observations have been made by 
Dr. Hirschfelder, who tests the undiluted and the diluted urine as a 
routine. In work done in this clinic we have been in the habit of 
testing the diluted, the concentrated, and the unaltered urine. I am 
told that certain urines giving no test according to usual technic give 
a good one if only one-half volume of reagent is used. 

What the body is which gives the red color when combined with 
a diazo is not known. One of the interesting recent suggestions is 
that of Bondziriski, who found alloxyproteinic acid in all normal urines 
11 



162 



CLINICAL DIAGNOSIS 



which, since it will give the test, he suggests as the cause. Clemens 
replied that this was not the important body since the body giving the 
diazo test is sulphur-free. 

Occurrence. — In health the test is never positive. Ehrlich has 
divided diseases into four groups. The first is that of non-febrile 
diseases, such as advanced heart disease, chronic hepatitis, carcinoma 
especially of the pylorus, leukaemia, marasmus senilis, malarial 
cachexia, tuberculous abscess, etc. In these it is rarely positive. 

Febrile Diseases. — These Ehrlich divides as follows: 

( 1 ) Those in which the test is almost never given, — e.g., acute 
articular rheumatism and meningitis. 

(2) Diseases in which it may or may not be positive, — as pneu- 
monia, scarlet fever, diphtheria, erysipelas, and phthisis. 

(3) Those in which it is almost constantly present, — typhoid 
fever and measles. 

Lobligeois in scarlet fever found the test positive in 42 of 52 cases, 
and in but 3 of 137 cases of diphtheria. He considers it therefore 
important in the diagnosis of cases of diphtheria with a scarlatinal rash 
— e.g., the serum erythema. Brunschwig found that in children the re- 
action is always positive in typhoid, often in scarlet fever, quite often in 
measles, rarely in pneumonia, and never in whooping-cough. Tropea 
and Brancati consider that the test is not very valuable, since it 
occurs so variably in some diseases, so often in others, and, they claim, 
in some normal persons. In disease they suppose it to depend upon 
the virulence of the organism and the products of the breaking down 
of body tissues. 

Ehrlich considers that in the first two groups of fevers, those in 
which it is almost never, and in those in which it is sometimes, present, 
the positive reaction means a poorer prognosis. In suspected typhoid 
fever it is agreed that its continued absence speaks strongly against that 
diagnosis, also that its reappearance allows of a differentiation between 
a relapse or recrudescence of the typhoid and a fever due to a compli- 
cation. Johnson found it present in over 80 per cent, of his cases. 
Montier found the test present in all cases of the pulmonary type of 
typhoid fever. Delearde and Hautefeuille 51 found the test positive in 
severe cases of typhoid fever, and considered that drugs had no influ- 
ence, nor did it bear any relation to intestinal putrefaction. Phenol 
is an important body to inhibit its appearance. Others consider that 
in typhoid fever it is of no value, inasmuch as it is often negative in 
the early stage of the disease when it is most needed. 

In phthisis it is supposed to indicate a bad prognosis, although the 
previous opinion of Michaelis that such cases were always fatal is not 
borne out by the experience of others. Boissiere found it in 18 of 130 

51 Compt.-rend. Soc. Biol., vol. liv. p. 279. 



THE URINE 



163 



severe cases. There is some reason to think that in tuberculosis it is 
due not to the tuberculosis but to some secondary infection. 

It cannot be used to distinguish between typhoid fever and miliary 
tuberculosis, since it is often positive in both conditions. It occurs 
also in puerperal fever and in actinomycosis of the lung. 

The work of Z'unz 52 is of particular interest to us, since it seems 
to have been done with exceptional care. His conclusions are that 
the value of the test is limited to the early diagnosis of typhoid fever 
and to the prognosis of tuberculous pneumonia, but that in the latter 
disease a positive reaction does not mean a hopeless prognosis ; that it 
is of diagnostic value in early cases of measles, and speaks in favor of 
tuberculosis in cases of peritonitis, pleurisy, and nephritis ; that it is 
often present in erysipelas; that if present, the prognosis in a case of 
cancer or sarcoma is more serious ; that in cases of pneumonia and 
pyothorax (non-tuberculous) the test means merely disturbed metab- 
olism; that in certain cardiac affections it speaks in favor of a 
reserved prognosis; and, in conclusion, that it is a useful test, although 
its value has been much exaggerated. 

Many consider that the ingestion of certain drugs prevents the test, 
as, for instance, phenol, salol, benzonaphthol ; not that these bodies 
inhibit the formation of substances giving the test, but that they them- 
selves unite with the reagent, thus preventing the reaction, and if they 
are extracted with amyl alcohol the test is positive. Zunz does not 
agree. 

Plezl 53 found it present in typhoid from the middle of the first to 
the end of the third week ; in measles, before the eruption and during^ 
the onset. His suggestion is that apart from these conditions it occurs 
in streptococcus septicaemia, which explains its presence in the angina 
of scarlet fever, advanced lung tuberculosis and other forms of severe 
tuberculosis, and in conditions with a general septicaemia. 

We find the test very valuable. When present it is strong evidence 
in favor of typhoid fever. In our typhoid cases the test very soon is 
negative, the result of the diuresis we encourage. 

Ehrlich's " Egg-Yellow Reaction."— Ehrlich has called attention to a some- 
what characteristic reaction in cases of pneumonia before and during the 
crisis. If the diazo test be tried, the urine and the foam take a yellow color before 
the addition of ammonia. After it is added the color changes to a lighter yellow. 
Ehrlich ascribes the reaction to the urobilogen formed from the urobilin of the 
exudate, and thinks that it predicts the crisis. Others think its value still uncer- 
tain. 

Ehrlich's Dimethylamidobenzaldehyde Reaction. — This is another color 
test proposed with the hope it would turn out of value. Dimethylamidobenzalde- 
hyde is dissolved in equal parts of cone. HC1 and H 2 0 to make a 2 per cent, 
solution. From 5 to 10 drops of this are added to a few cubic centimetres 
of urine in a test-tube. This is then agitated a few minutes or set aside, and 

52 Bull, de l'Acad. roy. de med. de Belgique, ser. iv., t. xiv. p. 553. 

53 Wien. klin. Wochenschr., 1903, No. 31. 



164 



CLINICAL DIAGNOSIS 



then the color noted. Normal urines give a greenish-yellow, but some patho- 
logical ones a distinct cherry-red color, which constitutes a positive test. This 
occurs in a variety of conditions, including phthisis, typhoid, and chronic enteritis. 
Fresh urine must be used and not heated. Nothing of value has resulted as yet. 54 

FERMENTS 

Ferments. — Several ferments have been demonstrated in the 
urine in health and in disease, in amounts depending on the general 
condition of the patient. The most important of these is pepsin. To 
demonstrate, pure fibrin is allowed to stand for several hours in the 
fresh urine. This will absorb a great deal of the pepsin. The fibrin 
is then removed, placed in dilute hydrochloric acid and this in a 
thermostat. If digestion occurs in acid medium pepsin is demon- 
strated. Matthes 55 has shown that a certain amount of the pepsin 
is reabsorbed. Trypsin, it is said, has been found, but this has not 
been confirmed. A diastatic ferment surely occurs in some cases 
and rennin as well. It is claimed that there is a ferment which breaks 
up the urea molecule forming ammonia bodies. Such ferment, how- 
ever, needs further demonstration. 

Clinically, pepsin is absent in the urine of cases of typhoid fever, 
gastric subacidity, and cancer. Some think that these ferments nor- 
mally are supplied to the gastric mucosa, etc., through the blood; 
others believe they are formed by these mucosae. Dell' Scola 57 holds 
the former opinion. He reports them diminished, even absent, in 
severe diseases of the nervous system. 

Lipase 58 is not present normally or only in traces. It is present 
in jaundice, perhaps in traces in diabetes mellitus, but is found 
especially in those conditions with fat necroses (in dogs after mechani- 
cal injury of the pancreas, after tying the pancreatic duct). 

Method (Kastle-Loewenhart) . — In each of three flasks are 
measured 5 cc. of urine. The second flask is boiled. To the third are 
added 3 drops of phenolphthalein ( 1 per cent. ) and it is titrated with 
tenth-normal NaOH till faintly pink. This amount of alkali is then 
added to flasks 1 and 2. To each of these is then added 0.25 cc. of 
ethylbutyrate and 0.1 cc. toluene, and they placed in a thermostat at 
39 0 C. for twenty hours. An amount of tenth-normal HC1, which is 
0.5 cc. more than the amount of tenth-normal NaOH previously 
added, is then added to each, they are shaken out with 50 cc. of ether 
and 25 cc. of alcohol, 3 drops of the phenolphthalein solution are 

54 Simon, Am. Jour. Med. Sci., 1903. 

85 Arch. f. Exp. Path., 1903, vol. xlix. p. 107. 

56 See Friedberger, Giessen, 1899. 

67 Centralbl. f. inn. Med., 1902, No. 14. 

58 See Hewlett, Jour. Med. Research, 1904, vol. vi. p. 377 ; also Gamier, Compt- 
rend., 1903, vol. v. p. 1064. 



THE UKINE 



1G5 



added to the ether extract and the amount of butyric acid split off 
titrated with tenth-normal KOH. 

In case 5 cc. of urine for each flask is not available the figure 
obtained from the smaller amount is calculated for 5 cc, using the 
formula that the amount of ferment action varies as the square root 
of the amount of ferment present. 

CARBOHYDRATES AND ALLIED BODIES IN THE URINE 

A small amount of carbohydrates is a normal ingredient of the 
urine. Three have been demonstrated, — glucose, animal gum, and iso- 
maltose. Related bodies are also present, — the paired glycuronic acid 
compounds, chondroidin-sulphuric acid, nucleinic acid, and the mu- 
coid of the nubecula, sometimes also pentose. The total output of these 
carbohydrates measured as glucose amounts to from 2 to 2.23 gins, in 
twenty-four hours. Of glucose there is normally from 0.38 to 0.62 
gm. in twenty- four hours (Naunyn, 0.4 to 1.4 gins.). 

The total carbohydrates, fermentable and unfermentable, may be determined 
as the benzoylester. The urine is made alkaline with NaOH and the phosphates 
filtered off. To the filtrate in a flask are added 4 cc. benzoylchloride per 100 cc. of 
urine, and 40 cc. of 10 per cent. NaOH, and shaken gently for ten minutes (to avoid 
emulsion), then vigorously for twenty to twenty-five minutes, till all odor of 
the benzoylchloride has disappeared. It is allowed to stand a few hours, not over 
night since the precipitate gets sticky and will not filter well, then filtered, the 
precipitate washed, dried over H2SO4, and weighed. 

The assimilation limit is an interesting as well as important con- 
ception in functional diagnosis. By this is meant the minimum 
amount of sugar the ingestion of which by mouth is followed by the 
excretion of a slight amount in the urine. A lesser amount the body 
can either oxidize or warehouse. Hofmeister found that galactose 
and lactose passed the most readily into the urine; dextrose, lsevu- 
lose, and cane-sugar much less so. 

After a meal of about 200 gms. of glucose a normal person excretes 
as a rule none, or seldom more than 1 gm. ; some persons none after 
300 gms. Some normal persons will excrete a little after smaller 
amounts ; for instance, of 50 gms. It occurs with greatest ease if the 
sugar is given on an empty stomach. Hunger lowers the assimilation 
limit considerably ; pregnancy also does the same. Diseases lowering 
the limit are cirrhosis of the liver, cerebral disease, poor nutrition, fatty 
liver, phosphorus poisoning and infectious diseases, certain neuroses, 
exophthalmic goitre, and any condition causing diuresis. 

Naunyn has divided cases of alimentary glycosuria into those fol- 
lowing the ingestion of starch, and those which follow the ingestion 
of sugar. The former denotes a disturbed metabolism very nearly if 
not always diabetic, for no matter how much starch (even 600 gms.) is 



166 



CLINICAL DIAGNOSIS 



ingested, no glycosuria should follow. This perhaps may be explained 
by the slow absorption of the products of starch digestion. 

All grades of weakness of sugar metabolism occur, from those 
with a slight lowering of the assimilation limit, to those in which 
glycosuria follows large doses of starch, and, finally, cases of true 
diabetes mellitus. 

The assimilation limit may be conveniently tested by the following 
test meal (Nauiryn) : At breakfast, coffee and milk (about 250 cc), 
and 80 to 100 gms. of bread are eaten. In about two hours 100 gms. 
of dextrose are taken at one time. Thus the sugar is not taken on 
an empty stomach. If a measurable glycosuria results the limit is 
pathologically lowered. If 1 per cent, of sugar is present the suspicion 
of diabetes is very pressing. The sugar excretion begins in about one 
hour, reaching maximum in from two to four hours, and lasts at the 
longest but eight to ten hours. If glycosuria follows a meal rich in 
starch foods the suspicion of diabetes is very strong indeed. 

In certain cases with an apparently lowered assimilation limit the 
suspicion of diabetes may be unjust, since it has been shown that if 
the sugar reaches the lower part of the small intestine it seems to be 
absorbed by the lymphatics, and so does not pass through the liver but 
at once into the circulation and is at once excreted. (On the prog- 
nosis of these cases of transient glycosuria, see Barringer and Roper, 
Am. Jour, of A. M. A., June, 1907.) 

The hunger diabetes of Hofmeister is very interesting. He found 
that if dogs under close confinement be kept on a poor diet, not starved, 
a certain number of them soon become diabetic and excrete 30 per cent, 
of the starch of their food as sugar. We presume that almost every 
one who has had much experience in metabolism experiments with 
dogs has found illustrations of this form of diabetes. Naunyn made 
the prophecy that this would soon be found to explain the glycosuria 
of certain chronic diseases of man, the disease bringing about a condi- 
tion of malnutrition. Soon after this the report of Hoppe-Seyler, 59 
of ten cases of temporary glycosuria in tramps who had been under 
very unsuitable hygienic and dietary conditions, the glycosuria disap- 
pearing in twenty-four hours after their physical condition had im- 
proved somewhat, was the first confirmation of this prophecy. 

Glycosuria. — That normally a small trace of glucose is pres- 
ent in the urine can be proved by isolating the glucosozone from large 
amounts of urine. Quantitative reduction tests before and after fer- 
mentation of the urine also indicate the presence of this body. 

Theoretically, glucose appears in the urine: (1) When in the 
blood it has reached 0.3 per cent, or over, that is, a distinct hyper- 
glycemia. A hyperglycemia may be due to the ingestion of more 

59 Miinch. med. Wochenschr., April, 1900. 



THE UKIKE: GLYC0SUE1A 



167 



sugar than can be warehoused or to the accumulation in the blood of 
glucose which the body cannot use, the function of the kidney being 
to excrete any excess over the physiological percentage of the blood. 
(2) When there is on the part of the kidneys a diminished ability to 
retain it, e.g., after phlorizin injection. (3) Some compound of glu- 
cose rendering it unfit for use. 

Clinically, the cases may be grouped according to Hammersten as 
follows : 

(1) Those with a lowered assimilation limit. In this group See- 
gen put his cases of mild diabetes. In such there is no glycosuria on 
a carbohydrate-free diet, the liver being able to warehouse well the 
sugar formed in the body. 

(2) Those with an excessive amount of glucose formed in the body 
at the expense of glycogen and other bodies. This occurs after certain 
experimental lesions of the brain and perhaps after certain cerebro- 
spinal diseases. Perhaps in this group also are to be included CO, 
curare, strychnine, and morphine poisoning. The source of the sugar 
is probably the albumin, since sugar appears in the urine only if the 
animal has had enough albumin. During albumin-hunger, even on 
a rich carbohydrate diet, no sugar is found. 

(3) Cases in which the body cannot use the glucose, and it there- 
fore collects in the blood. Severe cases of diabetes mellitus belong 
here. Such are not due to the inability of the body to burn the sugar, 
since the combustion ability of the patient has been proved normal. 
Levulose is well used for a while. Usually diabetics are unable to 
use the dextrose molecule alone, perhaps to produce the preliminary 
splitting of this molecule. All urinary changes are merely the result 
of this. According to Opie these cases belong to the following 
group. 

(4) After disease or removal of the pancreas. In dogs the glyco- 
suria may reach 10 or 22 per cent.; the animal lives not over four 
to five weeks. In such experimental cases practically all the sugar 
ingested is excreted, and in a quite constant ratio to N (2.8: 1) ; in 
analogous cases in man not quite all is excreted. In some cases is 
found atrophy of the pancreas or degeneration limited to the islands of 
Langerhans. 

(5) Glycosuria follows oxygen starvation due to any cause; suf- 
focation, the death agony; certain poisons, as CO, curare, and amyl 
nitrite; narcotics, as ether, chloroform. 60 

(6) Certain poisons, including morphia, strychnine, and cocaine; 81 
fusel oil, HgCl 2 , acids. In this connection the work of Herter 62 

60 See also Brown, Johns Hopkins Hosp. Bull., May, 1900. 

61 See also Neubauer and Vogel, p. 92. 

62 Am. Med., 1902, p. 771. 



168 



CLINICAL DIAGNOSIS 



is interesting, showing that the local application of reducing substances 
to the pancreas (adrenal extract and various poisons, H 2 S, KCN, H 2 - 
S0 4 ) causes glycosuria. Blum had shown that a substance from the 
adrenal caused glycosuria, and Metzger that this depended on hyper- 
glycemia. Herter thinks that it is the oxygen deprivation which is at 
fault. 

(7) After severe cooling of the body. 

(8) Renal diabetes. After caffeine or theobromine, or any 
diuretic which increases the secretion of the kidney. Phloridzin dia- 
betes shows the possibility of renal diabetes, and these are the only 
cases without hyperglycemia. In some cases of chronic nephritis one 
sees diabetes, but, as a rule, the former is secondary to the latter, 
and as the nephritis develops the glycosuria diminishes, the so-called 
" cure by Bright's disease." 

After the transfusion of normal salt solution; after the injection 
of sugar into the blood ; after insults and injuries to the liver, well 
seen in animal experiments ; a similar connection may explain the rare 
cases of cirrhosis of the liver with glycosuria; after diseases and 
injuries of the central nervous system, the best illustration of which is 
in animals, the piqure of Claude Bernard, causing hyperglycemia of 
even 0.7 per cent, due to the inability to retain the glycogen, which 
lasts from six to forty-eight hours, and a glycosuria which may reach 
in rabbits even 6 per cent. 

In man a similar glycosuria follows apoplexy, transient, as a rule, 
beginning in two hours and lasting even six days, reaching 1 to 2 per 
cent. ; brain tumors, especially of the base ; dementia paralytica com- 
monly ; epidemic cerebrospinal meningitis ; tabes ; multiple scleroses ; 
diseases of the sympathetic nervous system; severe trauma of 
the skull, in which case it is usually permanent, beginning at once or 
in a year, and mild as a rule, some with an interesting relation to dia- 
betes insipidus, beginning as this and ending as mellitus; functional 
neuroses ; psychical causes ; exophthalmic goitre ; gout ; arteriosclero- 
sis ; obesity. 

In pure diabetes no gross lesion is found (but see page 167). 
Such occurs especially in the young and includes nearly all severe cases, 

QUALITATIVE TESTS FOR GLUCOSE 

Trommer's Test. — To a test-tube half full of urine is added about 
one-third volume of 10 per cent. NaOH or KOH and then a 10 per 
cent, solution of CuS0 4 in drops, until a few flakes of Cu(OH) 2 do not 
disappear on slightly shaking. The upper layer of the urine is then 
warmed, when at once a precipitate yellow or red in color appears at 
the top. When this appears the heating should at once be stopped. 
The reduction and the precipitate will spread through the fluid from 



THE UKIKE: GLYCOSUKIA 



169 



above downward. The urine should always be examined fresh, and 
much albumin removed in all cases. 

The reaction is as follows : If to pure water be added KOH and then the 
C11SO4, the first drop of the latter will cause a precipitate of Cu(OH) 2 [CuS0 4 + 
2NaOH = Na 2 SO* + Cu(OH) 2 ]. These flakes of Cu(OH) 2 , on heating, will 
blacken, since Cu(OH) 2 2G1O is formed. If glycerin or the tartrates be added 
to the water, all of the Cu(OH) 2 is dissolved to a blue solution, which will not 
blacken on heating as it does if undissolved. If, instead of these, glucose be added 
to the water, the same blue solution of the Cu(OH) 2 is obtained. This, however, 
on warming is reduced, and a yellow or red precipitate falls. In the case of glu- 
cose the body giving the bright blue solution is C 6 Hi 2 0 6 5Cu(OH) 2 . 

In the normal urine certain bodies are present which, like glycerin et al., will 
dissolve the Cu(OH) 2 . Such are the ammonia bodies, both those preformed and 
those resulting from boiling an alkaline urine, and albumin if present. These, 
however, are present not in sufficient quantity to give a clear blue solution, and 
only 3 to 5 drops of the CuSO* can be added before some remains as a precipi- 
tate and that dissolved gives only a slight greenish color to the solution. If, how- 
ever, to the normal urine or in the reagents, glycerin, the tartrates, or more 
ammonia be added, more or' all of the Cu(OH) 2 will be dissolved, giving an 
azure blue solution varying in depth with the amount of Cu(OH) 2 added. 

But the normal urine also contains reducing bodies which will reduce the 
copper on warming. Such are uric acid, the glycuronic acid compounds, pyro- 
catechin, and bile pigments if present, and always a trace of glucose. But the sum 
of all these equals about 0.5 per cent, if expressed in glucose. These bodies, when 
present in normal amount, will reduce some of the copper and give a yellowish 
solution, a dirty not a clear yellow, and a little will be carried down with the 
phosphate precipitate, tingeing it. If these bodies normally present be increased, 
a definite precipitate, hence a positive test, may result. But uric acid does not 
reduce at a temperature of from 6o° to 70 0 C, and creatinin reduces much only 
after long boiling, although there is a little reduction at 6o° C. ; hence, as no high 
temperature is allowable in this test, these bodies should not confuse. They are 
very important, however, since they hold in solution the small amount of the 
suboxides which is always formed. The ability to hold in solution these reduced 
suboxides in the normal urine is much greater than its reducing ability, and hence 
glucose may be added to normal urine up to almost 0.5 per cent, before any precipi- 
tation occurs. The bodies holding the suboxides in solution are uric acid, creatinin, 
the ammonia salts, and albumin if present. 

In glycosuria we have a great increase in glucose, the chief reducing body, 
and because of the polyuria a relative decrease in the amount of those bodies 
preventing the precipitation of the cuprous salts. In performing the test it is par- 
ticularly important that the excess of copper should not be added since the black 
oxide will cover the precipitate of the cuprous salts. Normally 3 to 5 drops of the 
CuSOi are sufficient to give a blue precipitate. In case sugar is present, however, 
the addition must continue until the first flakes of Cu(OH) 2 remain. The test is 
positive only when a yellow or red precipitate falls, yellow Cu 2 (OH) 2 in a rela- 
tively weak alkaline, red Cu 2 0 in a strongly alkaline solution. (Neumayer 6a says 
it is the creatinin of the urine which causes the amorphous yellow rather than the 
crystalline red precipitate such as pure glucose solutions give.) When much alkali 
is used the creatinin is transformed to creatin. If much sugar is present, metallic 
copper may be deposited on the glass (it is often a problem to clean such test- 
tubes, and strong nitric acid is recommended). In case under 0.2 per cent, sugar 
is present there will be no precipitate, and yet even then the test may be very sug- 
gestive, since the yellow solution will be of such a clear brilliant color. Again, 
the precipitation should occur under the boiling point or when the urine is just 
brought to that point to exclude the reduction by those bodies normally present. 

For a successful test the proportions of the reagents should be rather accurate. 

^Deutsch. Arch. f. klin. Med., 1900, vol. xlvii. p. 197. 



170 



CLINICAL DIAGNOSIS 



Since one part of sugar can reduce about five parts of Cu(OH) 2 , as nearly this 
amount of copper as possible should be in the solution. Glucose alone, however, 
cannot dissolve as much cupric sulphate as it can reduce, and so glycerin, ammonia, 
or the tartrates are added to Fehling's, Purdy's, et ah, reagents, for they dissolve 
much cupric sulphate, which is then at the disposal of the glucose. The optimum 
relation is i part of glucose to 5 (3 to 7) of Cu(OH) 2 and 11 of NaOH. The 
excess of this last reagent is necessary, since the temperature of reduction de- 
pends directly upon it. If very little be present, a reduction may require hours 
of boiling. If but two parts of NaOH are present to one molecule of sugar, a few 
minutes' boiling is enough, while with an excess it is not even necessary to raise 
it to the boiling point to get a fair reduction. 

Again, the best chance of a precipitation occurs when there is present a mini- 
mal amount of those bodies which hold the reduced copper salt in solution. 
For this reason it is advised by many, as a matter of routine, to always dilute the 
urine about 1 : 5, this strong dilution ruling out the influence of these other bodies 
in a much greater proportion than it diminishes the reducing power of the glucose. 

If to a strong solution of glucose be added strong NaOH or KOH, then a little 
copper and the whole heated, a yellow or yellowish-brown or a dark-brown solu- 
tion is obtained, the color varying with the amount of sugar and alkali, since there 
is not enough copper in solution and some sugar is destroyed as in the Moore test. 
This color plus that of the suboxides gives a color which much surprises the stu- 
dents. It is avoided by trying the test anew and adding a great deal more copper. 

The best results are obtained if the copper be added before the alkali. More 
urine, however, must be added in case it is found that too much copper was used. 

In the Trommer's test the fluid should decolorize as the precipitate forms and 
before the boiling point is reached. The precipitation should occur while the urine 
is still hot, and not after it has cooled down. When, however, only a trace of 
sugar is present, the precipitate may fall only after long boiling or after cooling, 
but such a reaction is not positive. The brilliant color of the yellow solution may 
indicate sugar, but in such a case, if the urine be much diluted, the precipitate 
may occur in the desired manner. In order to rule out a mistake arising from 
long boiling, some add to the boiling urine one-third volume of cold NaOH and 
then copper. Some of the sugar, however, will have been destroyed by the alkali 
before the copper is added, and hence the test is not nearly as delicate. Since a 
normal urine reduces some copper, and would more could it dissolve more, 
ammoniacal urines may give a good precipitate since they dissolve more than acid 
urines. It is also true that the great excess of NaOH will dissolve some of the 
Cu 2 (OH) 2 , and in case of strong ammoniacal urine all of the cuprous salt may be. 
held in solution. It does no good to add more copper, since the sugar has by 
this time all been destroyed. In a normal urine it is possible sometimes to get a 
positive test by adding an excess of NaOH and too much copper. 

After warming there may be a clear yellow solution in a normal urine or a 
grayish-green shimmer due to a slight precipitate of the copper compounds of the 
xanthin bases and uric acid. The copper precipitated by sugar is crystalline, while 
that by the xanthin bases is amorphous. 

In all copper tests albumin does not hinder reduction, but does the precipita- 
tion, and hence must be removed unless but a trace is present, when it may be 
disregarded. 

The phosphate precipitate stained slightly yellow by the Cu 2 (OH) 2 formed 
even in normal urine often deceives. 

The urine may give a reduction when the glycuronic acid com- 
pounds are increased. Such follows the use of chloral hydrate, chloro- 
form, morphine, camphor, phenol, resorcin, thymol, and menthol. A 
positive reduction is obtained sometimes after the use of salicylic acid, 
benzoic acid, chrysophanic acid, oxalic acid, salol, thallin, santonin, 
copaiba, rhubarb, sulphonal, chloroform, acetphenetidin, glycerin; 



THE UEINE: GLYCOSURIA 



171 



after poisoning with KOH, H 2 S0 4 , and arsenic. In alkaptonuria the 
test is positive. Saccharin hinders the reduction. In addition to the 
reducing substances mentioned are to be added allantoin, mucin, pyro- 
catechin, hydrochinon, urobilin, perhaps also indican. 

We insist that the Trommer's test, although it is used but very little in 
practice in this country, shall be the one upon which the students shall practise 
the copper tests. The reason for this is that all steps in the process are evident, and 
the chances of error are very apparent, hence the difficulties of copper testing 
can be well learned through it. It is not so delicate as the Fehling's, and yet we 
have been interested to see those who have had the greatest experience in sugar 
work use this qualitative test as a routine matter. The reason for this is that 
it tells more than does the Fehling's, indicating the presence or the absence of 
certain bodies and in a rough way the amount of sugar that is present. If, for 
instance, the undiluted urine gives a barely positive test, 0.2 per cent, of sugar 
may be assumed, and from the amount of copper necessary to add for a good 
precipitation a rough approximation may be made. 

Fehling's Test Solution. — In Fehling's solution Rochelle salt is 
used that there may be a maximum amount of copper in solution, 
at least 5 of Cu(OH) 2 to 1 of glucose, and hence the optimum chance 
of precipitation without the possibility of a black precipitate. Feh- 
ling's solution is made from two fluids which must be kept separate, 
each quite permanent. 



The mixed solution will keep one day, but an old one may 
reduce on boiling. Equal amounts of these two fluids are mixed and 
brought to a boil. The urine is then added in small amounts until 
a precipitate is obtained, the amount of urine, however, never exceed- 
ing that of one of the solutions. The precipitate should appear at once. 
The mixture may be brought again to the boil, but prolonged boiling 
should be avoided; also a precipitate which forms after the urine has 
been allowed to stand does not necessarily indicate sugar. As usually 
performed, the amount of urine is added to the boiling Fehling's in 
one amount, yet by slowly adding one can guess pretty accurately* 
the amount of sugar present. The test shows 0.08 per cent, of glu- 
cose. Although more delicate, it should be remembered that this test 
has all the faults of the Trommer's. A normal urine will always 
reduce a little, but not if the urine is first diluted so that its specific 
gravity is 1005 (Zeehuisen). 

Almen-Ny lander's Test. — The solution consists of Rochelle salt 
4 gms., dissolved in 100 cc. of 10 per cent. NaOH (sp. gr. 1015) 
warm, and saturated with bismuth subnitrate (about 2 gms. are 
necessary). When cooled it is filtered and kept in a dark bottle. The 
solution is permanent for years. 



Solution A. 
Copper sulphate, 34.65 gm. 
Distilled water, q. s. ad 1000 cc. 



Solution B. 



Rochelle salt, 173. gm. 
Sodium hydrate, 125 gm. 
Distilled water, q. s. ad 1000 cc. 



172 



CLINICAL DIAGNOSIS 



To the urine is added one-tenth volume of this reagent. The mix- 
ture is then boiled from two to five minutes. If sugar be present, the 
fluid will turn black and a black precipitate of metallic bismuth will 
settle. Should it become black after cooling, the test is not necessarily 
positive. If only a trace of glucose is present, the white sediment of 
phosphates may be only slightly gray, especially on its upper surface. 
The boiling should be continued for five minutes, not less, since only 
too often will the urine suddenly darken contrary to the expectations 
of the observer. Since it is difficult to boil this urine so long (by 
the watch), it is much better to leave the tube in a boiling water-bath. 
If only a trace of sugar be present, the amount of reagent used, one- 
tenth volume of the urine, must be accurately measured. If this 
test is negative we may be sure no sugar is present. If faintly positive, 
the test must be confirmed, since bismuth is also reduced by certain 
paired glycuronic acid compounds sometimes present. This test is 
very delicate; in fact, is given, some say, by normal urine (14 per 
cent, of cases). Uroerythrin may deceive, since it simulates the test; 
also haematoporphyrin. Concentrated urines may give a positive test. 
The test will indicate 0.05 per cent, (others say 0.025 P er cent.). Any 
increase or diminution in the alkalinity of the fluid injures the delicacy 
of the test, hence it should be applied carefully in an ammoniacal 
urine. If the sugar is over 0.2 per cent, the yellow color of the 
Moore test is first seen. Rhubarb and senna will give a reduction, but 
before heating it will be noted that the fluid takes a brownish-red 
color. The test is positive after salol, benzol, sulphonal, trional, anti- 
pyrin, kairin, much quinine, eucalyptus tincture and oil of turpentine. 
It is also positive after a person has eaten asparagus, a fruitful source 
of error. All of the albumin should be removed unless it be but a 
mere trace, since the Bi 2 S 3 , if precipitated in considerable amount, is 
of a brownish color ; if very little, a red. Ammoniacal urines are dis- 
turbing, since the NaOH replaces the ammonia, which is volatilized, 
leaving the solution not alkaline enough. This test is very valuable, 
since it is a very good control of the copper tests. Nylander's fluid is 
not reduced by uric acid, creatinin, pyrocatechin, hydrochinon, nor the 
alkapton bodies, and these are the greatest sources of error. 

Fermentation. — This is necessary to prove that the reducing body 
is a sugar of three or a multiple of three carbon atoms (yet not all of 
these ferment). Fresh active yeast should be used. A piece about the 
size of a pea is added to the urine, which is then gently shaken (if 
shaken too hard the amount of air in solution will be increased and 
afterwards give a bubble suspiciously large), and the urine then filled 
into a fermentation tube. This is let stand at the optimum temperature 
of from 1 5 0 to 34 0 C, and the presence of gas determined in a few 
hours. Two control tests should always be made : the one with normal 



THE UBINE: GLYCOSUEIA 



173 



urine to which a little glucose is added, to prove the activity oif the 
yeast ; another of normal urine alone, to prove by the absence of gas 
that there is no self-fermentation of the yeast. Above 45 ° C. there is 
no fermentation. The rapidity depends to a certain extent on the 
amount of the yeast. The amount of gas formed from a given amount 
of sugar, however, depends on the age of yeast, there being less formed 
the older it is. The maximum production of C0 2 (46.5 per cent, 
of the sugar) is obtained only when to one part of sugar is added not 
more than one-half of fresh yeast. If more yeast be used self -fermen- 
tation may result. This test indicates from 0.1 to 0.05 per cent, when 
boiled urine is used. 

Some consider it necessary to prove that the gas which was liberated is CO2. 
This is easily shown by dissolving it in NaOH. Some consider it necessary to 
prove also that alcohol was formed. This is easily done by distilling the fluid, 
adding to the distillate a little NaOH and some Lugol's solution, then warming it, 
and allowing it to stand for some hours. Crystals of iodoform will form if alcohol 
or acetone was present in the distillate. Or to the distillate may be added a little 
very dilute solution of potassium bichromate and a little sulphuric acid. The fluid 
then on heating will turn green and give off the odor of aldehyde. 

To exclude bacterial action the fermentation should occur within a few hours. 
Or bacterial growth may be inhibited by the addition of NaF, enough to make a 
. 1 per cent, solution, or by tartaric acid. Many recommend boiling the urine first 
for about ten minutes to sterilize it and also to free it from air. 

If only a trace of glucose is present there may be no C0 2 seen, 
since the urine can dissolve some, but the positive Nylander will dis- 
appear after long fermentation. 

Phenylhydrazin. — This test is the court of last appeal in the recog- 
nition of those carbohydrates which form with phenylhydrazin osa- 
zones of definite crystalline shape and with a definite melting point. 
In any case albumin must be removed, for it hinders crystallization. 
Ten cubic centimetres of urine are precipitated with a few drops of 
concentrated PbAc and filtered. One drop of acetic acid is added 
(or enough to acidify), then a piece of HCl-phenylhydrazin the size 
of a pea, and of NaAc the size of a bean. The tube is then boiled in 
a water-bath from one to two hours, its contents filtered hot, and the 
tube returned to the water-bath, which is allowed to cool down slowly. 
If much glucose was present there will be a deposit of yellow crystals in 
the form of needles arranged in sheaths. That the test may succeed, 
the sugar should be to the phenylhydrazin and the NaAc as 1:2:3. 

V. Jaksch recommends the following : To a test-tube containing 6 to 8 cc. 
of urine are added two knife-points of HCl-phenylhydrazin and three of NaAc. 
If these salts do not dissolve on warming, a little more water is added. The tube 
is then put in boiling water and allowed to stand from one-half to one hour (this 
time prevents the mistake with glycuronic acid compounds). The tube is then put 
in a beaker of cool water and the crystals searched for microscopically. It were 
better to let the solution cool down more slowly. This method has been severely 
criticised. 



174 



CLINICAL DIAGNOSIS 



The Neumann method, much recommended by Thierfelder, is as 
follows : To 5 cc. of urine are added 2 cc. of 50 per cent, acetic acid 
saturated with NaAc, and then 2 drops of pure phenylhydrazin. This 
is concentrated by boiling to 3 cc. It is then cooled rapidly. The tube 
is then warmed and allowed to cool very slowly. If there be 0.02 to 
0.05 per cent, of glucose present, in from five to ten minutes the crys- 
tals may be seen without admixture of other precipitate. Neumann 
recommended special graduated test-tubes. 

The crystals of phenylglucosazon should be filtered out, dissolved 
in hot 60 per cent, alcohol, and allowed to recrystallize by adding 
water and boiling the alcohol away. The purified crystals should then 
be tested as regards their melting point. If pure, they will melt at 
from 204 0 to 205 0 C. ; when impure, from 173 0 to 194 0 C. 

A very simple method of determining the melting point is as 
follows (see Fig. 24) : A small flask, A, is filled three-quarters full 
with concentrated sulphuric acid. Through a perforated stopper is 
inserted a test-tube, B, also one-half full of the same acid. Into 
this dips a thermometer, C, to which is attached a tube, D, con- 
taining the crystals. This tube has a lumen about 1 mm. in diameter 
and closed at its lower end, and into it are dropped the dried crystals. 
Very few are required. The tube is attached by a rubber band to the 
thermometer (of course at a point above the level of the acid). The 
flask is then warmed slowly with a Bunsen burner and the point noted 
at which the crystals melt. The precipitate is of yellow needles in 
sheaves, which are difficultly soluble in water and in hot absolute 
alcohol, easily soluble in 60 per cent, hot alcohol, and crystallize out 
if water be added and the alcohol evaporated off. They are insoluble 
in ether, chloroform, etc., but soluble in glacial acetic acid. Their 
solution is laevorotatory. 

So delicate is this test that, theoretically (if special technic be used), the small 
amount of glucose of normal urine will give a definite precipitate, seen microscopi- 
cally, but practically it does not ; Zunz has never found definite crystals except in 
such urines as reduce Fehling's. Theoretically it shows 0.003 per cent, and is too 1 
delicate for practical use, and yet we know of one insurance company which re- 
fused a man because of glycosuria detected by this test alone. On the other hand, 
it may fail entirely when the sugar is known to be present. The success depends 
on the amount of reagents used and on the time allowed to cool. Not all of the 
glucose is precipitated, the amount of precipitate depending on the concentration 
of the glucose and the relation between the reagents. From a 5 per cent, glucose 
solution the maximum precipitation obtained by Fischer was from 85 to 90 per 
cent. Much depends on the purity of the phenylhydrazin. The preference given 
to the HCl-phenylhydrazin is that it is crystalline and not a fluid at ordinary room 
temperature. 

The glycuronic acid compounds will give the same test, but the 
melting point of these crystals is lower, — 114 0 to 115 0 C. Various 
sugars give crystals. In pentose is the greatest danger of error with 



THE UKINE: GLYCOSURIA 



175 



the other tests, and hence the use of this is most important, since the 
crystals obtained melt at 159 0 to 160 0 C. 

Of the sugars, it is given by all of those reducing copper, including 
also lactose and maltose. Those sugars which differ only in the first 




Fig. 24. — Melting point of crystals. A, flask, and B, test-tube of sulphuric acid ; C, thermometer; 
D, fine-bore tube for crystals. 

two carbon atoms, with the rest of the formula the same, as, for in- 
stance, glucose, fructose, and mannose, give this same osozone. Other 



176 



CLINICAL DIAGNOSIS 



crystals are formed with acetone, hydrazin, oxalic acid, and uric acid. 
These, however, are not dangerous in human urine, since they do not 
occur in sufficient amount, and pentose is really the only one to exclude. 

With the crystals also is a precipitate of brown scales and oily droplets seen 
even when a pure solution of glucose is used. This by-product is G2H12N2, and can 
be washed out with chloroform or 95 per cent, alcohol and then the glucozone 
recrystallized from 60 per cent, alcohol. Should only brown scales or yellow amor- 
phous precipitate or droplets be found, the test is negative, although glucose may be 
present. 

In review it may be emphasized that there is nothing characteristic 
in the shape of the crystals ; their best solvent is 60 per cent, alcohol ; 
they are best recrystallized by pouring the 60 per cent, alcoholic solu- 
tion into water and evaporating the alcohol; the hot glacial acetic 
acid solution, which is soon destroyed, may be tested with the polari- 
scope ; that in testing the melting point one cannot expect to get 
exactly 204 0 to 205 0 C. 7 so much depends on the purity of the crystals 
and on the speed with which the temperature is raised. The latter 
.should be done as rapidly as possible, since by slow heating the point 
may be much lowered. This glucosazon differs from galacosazon by 
the lsevorotation of its glacial acetic acid solution, since that of the 
latter is optically inactive ; otherwise they are very similar. 

Zunz 64 considers this test one of the most important clinically, 
and for the further separation of the carbohydrates of the urine we 
give the table he recommends. 

Fermentation f Dextrorotatory. Glucose. 



to r 

"tao 



Gives crystals 

with 
phenylhydrazin 
directly in 
urine. 



Melting point 

of crystals 
about 200 0 C. 



positive. [ Laevorotatory. Levulose. 

Fermentation T 

,. Lactose. 

negative. 



Melting point r Give orcin reaction. Pentoses, 
of crystals J 

about 150 0 C. [ Do not give orcin reaction. Isomaltose. 

Gives crystals with phenylhydrazin only after the urine has f Paired glycuronic 
been warmed with dilute sulphuric acid. I acid compounds. 

The polarise ope is a very valuable instrument. In the recognition 
of traces of sugar care must be used, since most urines normally are 
slightly laevorotatory and some urines are dextrorotatory when sugar 
is absent (Borntrager in two morphia habitues). Albumin is laevo- 
rotatory, hence may cover a slight dextrorotation. The ordinary 
instrument will detect but about 0.2 per cent, of glucose. The test is 
of value if the urine be tested before and after fermentation. 

Rubner's Test. — This is a modification of the Moore-Heller test. Ten cc. 
of urine are mixed with an equal amount of PbAc, 1 to 10 solution, and the urine 
filtered. Ammonia is then added drop by drop until the caseous precipitate just 

64 Jour. Med. de Bruxelles, July 10, 1902. 



THE UELNE : GLYCOSUKIA 



177 



remains. The tube is then warmed in a bath at 8o° C, according to some, but 
heated to boiling according to Hoppe-Seyler and Hammarsten. If glucose be 
present a fine rose-red color results. 

Or, to 10 cc. of urine add 3 gms. of the dry PbAc and dissolve by boiling; 
then filter. To the hot filtrate add NH 4 OH and boil hard. It is well to dilute the 
urine that its specific gravity does not exceed 1010. 

If the urine be concentrated it should be diluted one-half with water. Hoppe- 
Seyler recommends that it be boiled for some time before ammonia is added, 
and this is to be added to the boiling solution. If it be heated too strongly, how- 
ever, a non-characteristic brown color appears. If it be warmed only to 8o° C. 
the test indicates glucose, and lactose is excluded. An excess of ammonia ruins 
the test, hence Voit says to add 0.5 volume of PbAc solution and 0.1 volume of 
NH4OH ; the urine is then filtered and the filtrate heated. To the hot filtrate is 
added more ammonia. 

Heat Test. — An easy test, sometimes valuable and more delicate than one 
would imagine and always possible, is the following : One drop of urine is evap- 
orated to dryness in a porcelain dish. It is then warmed gently. A yellowish- 
brown mass with an odor of caramels is formed at a temperature of 190 0 to 200 0 C. 

Moore's Test. — Moore's test is one of the first used for sugar. To the urine 
is added one-fourth volume of KOH or NaOH. On warming is obtained, first, a 
yellow, then an orange, and finally a dark brown color with an odor of caramels, 
clearer if the urine be acidified. It may be necessary to boil for some time. It 
occurs slowly at room temperature. It is the least delicate test. Sometimes a 
normal urine will darken somewhat, also a urine rich in mucus. The nature of 
the colored body is not known. The names glucinic acid and melasinic acid have 
been suggested, one of which, probably CH3COCH2OH, will reduce CuSO* in the 
cold. 

Choice of Method. — Any very positive reduction test indicates sugar. 
If Nylander's test is only suggestive, it is of value only when we 
know that the urine did not contain an excess of ammonia, and that 
it was boiled for some time. The urine may then be polarized, but 
the presence of a slight amount of sugar may escape this test from 
the presence of lsevorotatory bodies. In all cases albumin must be 
removed. As a routine reduction test Nylander's is the one to be 
recommended. Hammarsten recommends that physicians try this 
first. If negative, no sugar is present. If positive, try fermentation. 
If this is positive, glucose is the sugar. For the practitioner the fer- 
mentation alone is perhaps the best, since it leads to less confusion. 

In clearing the urine for further tests it must be remembered that 
glucose is not precipitated by sugar of lead, but is almost completely 
by basic lead acetate. 

Quantitative Determination of Glucose. — When sugar is 
known to be present and in good amount, a rough estimate of its 
amount is possible by the use of Naunyn's table : 

2 litres of urine of specific gravity 1028 to 1030 = 2 to 3 per cent 

3 litres of urine of specific gravity 1028 to 1032 == 3 to 5 per cent. 

5 litres of urine of specific gravity 1030 to 1035 = 5 to 7 per cent. 

6 to 10 litres of urine of specific gravity 1030 to 1042 = 6 to 10 per cent. 

In thus estimating the sugar from the specific gravity, and in the 
following calculation, using the coefficient 230, it is assumed that the 
12 



178 



CLINICAL DIAGNOSIS 



change in specific gravity is due alone to the sugar, which is not strictly 
justifiable, since urea and the chlorides also change somewhat. 

Suppose the diabetic urine was 3 litres in amount and of specific 
2 X 1-015 + 1. 000 

gravity 1030. Then = 1.010, the specific gravity 

3 

of normal urine if diluted to three litres (on the basis that a normal 
person voids two litres with a specific gravity of 1015). 1.030 — 
1.010 = 0.020, 0.020 X 230 = 4.6 per cent. 

2 X 1. 015 + 4.000 

In the same way 6 litres at 1030. =1.005. 

6 

1.030 — 1.005=0.025, 0.025 X 230 = 5.8 per cent. 

Quantitative Determinations of Glucose. — The best modification of Feh- 
ling's quantitative method is that of Purdy as further modified by Sahli (Deut. 
med. Wochenschr., Sept. 7, 1905). 

Solution I. Pure crystallized copper sulphate, 4.158 gm. 
Distilled water, q. s. ad 500 cc. 

Solution II. Rochelle salt, 20.4 gm. 

Pure potassium hydroxide, 20.4 gm. 
Ammonia (Sp. gr. 0.88), 300 cc. 
Distilled water, q. s. ad 500 cc. 

For a determination 5 cc. of each fluid are used. These 10 cc. (of the mixed fluid) 
will indicate 0.005 gm- of glucose. 

Procedure. — Five cubic centimetres of Solution I and 5 cc. of Solution II are 
carefully measured with a pipette into a small Erlenmeyer flask (of 75 to 100 cc. 
capacity), and 30 cc. of distilled water added. The flask is then heated till it just 
boils. It should rest on a tripod about 20 cm. tall which is covered with asbestos 
gauze, or asbestos sheet, or if these are not available, on an iron or nickel sheet 
covered with a layer of magnesia a few millimetres thick. The gas burner used 
should be one which allows accurate regulation of the flame. The diluted urine is 
added slowly from a burette, which is better held in the hand than fastened to an 
upright by a clamp. 

When the fluid in the flask just boils the diluted urine is slowly added, the 
fluid just boiling all the time, until the last trace of blue disappears. 

It is better to use distilled water than tap water to dilute the copper solution 
since the alkali may precipitate from the tap water a faint cloud of the alkaline 

earths. 

One of the most delicate parts of the determination is the dilution of the urine. 
This must be done with extreme accuracy. The best results are obtained when just 
10 cc. of the dilute urine were used to reduce the 10 cc. of the mixed copper 
solution. This means that the diluted urine should contain from 0.05 to 0.1 
per cent, of sugar, that is that a urine containing 5 per cent, of sugar must 
be diluted fifty times. Such a dilution can be made best by measuring the urine 
from a burette, or accurate pipette, into a volumetric flask with narrow marked 
neck, and the fluid then very thoroughly shaken. The amount of dilution is de- 
termined by a preliminary rough determination, or by an estimation with the 
polariscope. 

Benedict's Method (New York M. J., Sept. 14, 1907). — This method promises 
to be one of the best for the volumetric determination-of glucose. We continue in 
the author's words. • 



THE UKINE: GLYCOSUKIA 



179 



The solutions required are : 

Solution A. Crystallized copper sulphate, 69.3 gms. 
Distilled water, to 1000 cc. 

Solution B. Pure Rochelle salt, 346.0 gms. 

Anhydrous sodium carbonate, 200.0 gms. 
Distilled water, to 1000 cc. 

Solution C. Potassium sulphocyanate, 200.0 gms. 
Distilled water, to 1000 cc. 

For use these solutions are mixed in equal proportions. Thirty cubic centi- 
metres of the resulting solution are equivalent approximately to 0.073 gramme 
of dextrose. 

The Process. — To thirty cubic centimetres of the mixed volumetric solution in a 
beaker is added two or three grammes of anhydrous sodium carbonate * and the 
mixture boiled until this is dissolved. The urine to be titrated is now run in 
from a burette rather rapidly (not so quickly as to interfere markedly with 
continuous boiling) until a heavy chalk white precipitate is formed and the dark 
blue color of the solution begins to lessen perceptibly, whereupon . the fluid from 
the burette is run in more slowly until the blue color just completely disappears. 
The last portion should be introduced in quantities of from two to ten drops 
(depending on depth of color remaining and the relative strength of the sugar 
solution) with vigorous boiling of about one fourth minute between each addition. 
The end point (disappearance of the blue color) is sharp and satisfactory. 

A simple device to prevent the bumping of solutions during the process of 
titration consists in placing in the titration beaker a medium sized piece of pure, 
previously well washed absorbent cotton. By stirring this about with a glass rod 
as the titration proceeds, it is possible to entirely prevent the bumping which 
otherwise may become troublesome. 

Certain substances (notably chloroform) may occasionally be encountered, 
which interfere slightly with the titration by causing a portion of the reduced 
copper to be precipitated as the suboxide even in the presence of the sulphocyanate. 
In case such substances are present the following solution (solution D) should be 
used in place of solution C : 

The formula for solution D is 

Potassium ferrocyanide, 30.0 gms. ; 
Potassium sulphocyanate, 125.0 gms. ; 
Anhydrous sodium carbonate, 100.00 gms. ; 
Distilled water, to 1000 cc. 

This solution is used just as is solution C and will obviate any difficulties from 
interfering substances. Solution D does not alter the value of the copper solution 
in terms of dextrose, and may be used entirely in place of solution C if desired. 
Since, however, interfering substances are seldom, if ever, encountered, and solution 
C is a little more easily made up than is the other, solution C is recommended for 
ordinary use. 

If very little sugar be present, the urine (1500 cc.) may be precipitated with 
sugar of lead, then the filtrate precipitated with basic lead acetate and a little 
ammonia. The precipitate is suspended in alcohol and decomposed with H2S. The 
filtrate is then cleared with animal charcoal if necessary and evaporated at low 
temperature to a small volume. The amount of glucose in this solution is then 
determined with the polariscope. To exclude lactose and bile acids, both of which 
would, if present in the urine, be determined as well since they are dextrorotatory, 
the alcohol is evaporated off, the residue dissolved in water, yeast added, the glucose 
fermented ; the fluid is then filtered, the precipitate being washed with alcohol, 
the original volume restored and again polarized. 

* Double the quantity of the crystallized salt may be used. 



180 



CLERICAL DIAGNOSIS 



Fehling's Quantitative Method. — The formulas for these two solu- 
tions are given on page 171. Ten cubic centimetres of Solution A 
are reduced by just 50 mg. of glucose. 

Ten cubic centimetres of Solution A, and ten of Solution B. are 
carefully measured into an Erlenmeyer flask of about 250 cc. capacity. 
About 40 cc. of distilled water are then added and the fluid brought 
to a boil. The urine, so carefully diluted that it contains between 0.5 
and 1.0 per cent, of glucose, is added from a burette to the boiling- 
copper solution, until the blue color of the copper has just disappeared. 
Then, supposing a to represent the amount of diluted urine added, 

50 

— X 100 = the percentage of glucose in the diluted urine. 

a 

The first determination is only approximate. The diluted urine is 
added one cubic centimetre at a time until the end reaction. Suppose 
that 8 cc. were not enough, and 9 cc. were too much, then a second 
determination is made by adding 8.5 cc. in one amount. Suppose that 
the copper is all reduced by the amount, then five flasks are filled with 
the Fehling's solution and all brought to a boil. To one 8 cc. of 
diluted urine are added, to the second 8.1 cc, to the third 8.2 cc, etc 
Suppose the flask to which 8.2 cc. were added is just a trifle blue, that 
to which 8.3 cc is clear, then 8.3 cc. of diluted urine must contain 
50 mg. of glucose. 

This method is one of the most difficult of quantitative determina- 
tions in clinical chemistry. The end reaction is uncertain owing to 
the abundant red precipitate, and the rapidity with which the cuprous 
salt is reoxidized by exposure to the air. For this reason the urine 
must be added in one amount, the fluid then brought just to the boiling 
point, and the flask at once removed from the flame. In a few 
moments the precipitate will have settled just enough to allow the 
color of the uppermost layer of fluid to be determined. 

For Lehmann's method, see Sahli (1905) and Citron. 65 

Polaviscopc. — For this very important test and quantitative method 
the urine must be perfectly clear, so that through the tube of the 
polariscope when filled even the finest type may be very easily read. 
All albumin must be removed, since it is laevorotatory. The urine is 
best cleared, if possible, with Kieselguhr alone. An excess of this is 
added, the urine well stirred and filtered. The first of the filtrate is to 
be poured back into the funnel. If, as sometimes happens, this does 
not clear perfectly, crystals of sugar of lead are to be added and the 
urine filtered, or these two methods may be combined. 

The crystals are somewhat preferable to the solution, which changes the volume 
of the urine. But some prefer to add 10 cc. of PbAc solution (25 gms. in 100 

63 Deut. med. Wochenschr., No. 44, 1904. 



THE UBDnE: GLYCOSURIA 



181 



cc.) to 90 cc. urine, and this clears the urine perhaps better. Basic lead acetate can- 
not be used. Kieselguhr is recommended since lead acetate in any excess alters 
the physical properties of the fluid and does remove some glucose from urine, 
although none from a pure glucose solution, and yet Kieselguhr also may remove 
some sugar. Others recommend a small amount of PbAc and a teaspoonful of 
Na : SOi (added after the sugar of lead is dissolved). 



The tube is then filled, care being taken that no air-bubbles be 
enclosed, and the angle of rotation measured by the scale on B (Fig. 
25), using the vernier, C, for the fractions of a degree. 




Fig. 25. — Half-shadow saccharometer. A, ocular used in focussing the field ; B, graduated disk; C, 
vernier ; D, lever for rotating analyzer ; E, tube for urine ; F, glass disk ; and G, cap for end. 



The tube, E, is first cleaned thoroughly and dried. The glass disk, F, of 
the ends are perfectly clean and clear. One glass is screwed in and then the tube 
filled with the perfectly clear urine till the meniscus is convex. The second glass 
disk is then slid on from the side, pushing off the excess of urine and allowing no 
air to enter, and the metal cap, G, screwed down over this. 

The student should understand the instrument that he is using. There are 
many varieties on the market with slight differences in their construction and 
greater in their usage. It is seldom, of course, that a real polariscope is used, but 



182 



CLIXICAL DIAGNOSIS 



instruments modified for clinical purposes. The polariscope is an instrument which 
measures the angle of rotation caused by an active substance ; the length of the 
tube is usually 10 cm. or multiples of this, and the reading is in degrees. The 
specific rotation of glucose is [a] D = 52.74 0 . If a polariscope be used, there- 
fore, the angle of rotation must be divided by 0.527 to give the percentage of sugar. 
Those in clinical use are usually " half-shadow instruments," and simplified by 
using tubes of such length — 188.6 mm. (better 189.4 mm.) — that one degree of 
rotation will equal one per cent, of glucose. Each instrument usually has an- 
other tube, one-half as long, — 94.3 mm. (better 94.7 mm.), — for highly colored 
urine. Another instrument which is very popular and much more convenient is 
the saccharometer, in which the rotation by the sugar is to be balanced by a com- 
pensating quartz wedge which is marked with an empirical scale. The great ad- 
vantage of this instrument is that ordinary white light, as the Welsbach burner, 
can be used; in the other instrument a sodium flame only. 

In using, the field must be first focussed at A and the zero point 
determined. This changes somewhat with the temperature, particu- 
larly in the carelessly used instrument. The tube is then inserted, the 
field focussed sharply, and the rotation determined. The accuracy with 
which this can be done will depend upon the clearness of the field 
which depends on the fluid and focus, the sensitiveness of the instru- 



Figs. 26 and 27.— The fields as seen in the two most common types of clinfcal saccharometers. The 
central figures, gray fields with halves of equal illumination, are the zero points. The others are the 
fields with too little and too much rotation. 



ment, and the brightness of the light. To find the end-point with fields 
of equal illumination there are two common methods. In the one case, 
the analyzer is rotated until a black band seems to cross the division 
of the fields. This shadow, purely subjective, is yet of great value. It 
always appears a little too soon, therefore an average of the readings 
made from both directions should be used. In the second method 
the analyzer is slowly turned, always in the same direction, the eye 
being used but for a few seconds at a time, until the end-point seems 
to be just reached, that is, where there is no perceptible difference be- 
tween the two fields. This point will always be attained a little too 
soon, and in amount equal to the sensitiveness of the instrument. 
Hence, also, several readings should be made, turning from both direc- 
tions, and an average taken. In all cases it should be remembered that 



o 

c 





THE UK1KE: GLYCOSURIA 



183 



the eye should be used but for a few seconds at a time, not over fifteen, 
to prevent fatiguing the retina. The depth of illumination of the 
whole field should be judged, and not of contiguous portions. 

The half-shadow instruments, modifications of the Laurent, have been con- 
structed so sensitive that they allow one to appreciate a difference of only 0.02 0 , 
but it should be remembered that the principle on which the instrument rests is 
itself inaccurate to about 0.2 per cent., hence one gains very little from these very 
minute readings and some very careful work has only the appearance of accuracy. 

The ends of the tube must be planed at a right angle to its long axis. If theii 
axis forms an angle of over ten degrees its use is impossible. This is easily recog- 
nized by putting a tube in the instrument, focussing carefully, and then revolving 
the tube. The same effect is produced as if the analyzer were rotated. Leather 
washers are necessary to prevent too much tension of the metal cap upon the 
glass disk covering the end. If this glass is subjected to too high tension, it be- 
comes doubly refractive and a similar error arises. For this reason before any 
readings are made the tube should be rolled between the fingers. If this causes 
the two fields to change in relative intensity, it may indicate one of the tw r o above 
mentioned errors. If the whole of the field is not equally sharp the solution is either 
not homogeneous or the tube is dirty. This also is recognized by rolling the tube. 

The normal urine is slightly laevorotatory ( 0.005 0 to o. 18 0 ). A 
trace of sugar may therefore be present if the reading is practically 
zero. In some cases the urine is dextrorotatory when glucose is not 
present. Such were two cases of morphia habit (Borntrager). A 
polariscope is an instrument for the laboratory ; for the practical man 
it is a great (though expensive) aid in quantitative work. Albumin 
must be removed, it being laevorotatory. Should the worker make up 
a glucose solution and test it with the polariscope, he must remember 
to use a solution which has stood for at least a day, since glucose shows 
a birotation when first dissolved. 

Fermentation : Specific Gravity Method of Roberts. 66 — The 
amount of sugar is estimated from the difference in specific gravity, 
before and after fermentation. The urine should be acidified, if neces- 
sary, with tartaric acid. The specific gravity is first carefully de- 
termined, using a very accurate aerometer and paying due regard to 
the temperature of the fluid. A piece of washed yeast the size of a 
hazel-nut is then added and the urine allowed to ferment at from 15 0 
to 35° C. (a temperature of 34 0 C. is the best) until it gives no further 
qualitative test for sugar. This takes from twenty-four to forty-eight 
hours. The sediment is brought into suspension and the specific grav- 
ity again tested. The difference in the specific gravity multiplied by 
234 gives the percentage of sugar. It is better to use the pyenometer 
method of determining specific gravity, since the aerometrical 
method, which at the best is poor, is hardly delicate enough for this 
work. With accurate work the results are correct to 0.1 per cent. 
Albumin need not be removed. The sugar should be at least 0.5 per 

66 Edinb. Med. Jour., October, 1861, p. 326. 



184 



CLINICAL DIAGNOSIS 



cent. A greater accuracy is therefore claimed for this than for Feh- 
ling's method. 

Fermentation: Gas- Volumetric Method. — The Einhorn method of 
deterrhining the amount of sugar by the amount of carbon dioxide 
produced is thought by many to be a failure, since the amount of 
gas produced depends on the amount of yeast, its activity, the tem- 
perature, and many other factors ; yet it is possible to control well all 
of these factors, and we have seen excellent results with it. Lohn- 
stein's 67 instrument is said to be accurate and to give the result in 
six hours. 

The Roberts method is the best for the practitioner who has not a 
polariscope nor the time for the titration. The factor used in de- 
termining the per cent, will be found to vary in various text-books, 
but the one to use will depend on the method employed, each modifica- 
tion necessitating a different coefficient. Unless one is careful in the 
details, an error as high as 5 per cent, of the total amount may be 
made. 

Levulose is a sugar widely spread in the vegetable kingdom, par- 
ticularly among the fruits. It is often present in the urine of diabetics, 
but associated with glucose. There are, however, a few cases of pure 
lsevulosuria on record (Naunyn) in which this sugar was present in 
about 1 to 2 per cent. ; but, as a rule, there is less than 1 per cent. 
Rosin and Laband reported recently 6,8 an interesting case of pure 
lsevulosuria (0.6 per cent, in the urine. There was a lsevulossemia of 
0.5 per cent, even when the urine was negative), and uninfluenced by 
the ingestion of even 100 gins, of levulose or glucose. It is interesting 
that it is excreted, since levulose is the sugar most easily used by some 
diabetics, but by no means by all. If large doses are given, it is 
excreted almost entirely as glucose. In non-diabetic persons lsevulo- 
suria may occur spontaneously. 

Most of the reported cases of lsevulosuria are doubtful, since 
other lsevorotatory bodies were not excluded. Lsevulosuria is to be sus- 
pected when the percentage of sugar determined by polarization is less 
than that by titration, and the lsevorotatory body is fermentable. In 
sixteen cases Rosin and Laband found a lsevorotation (titration minus 
polarization) of from 0.3 to 1.7 per cent, (as glucose). No acetone 
was present. 

The most important lsevorotatory sugars are laiose and fructose. 
Fructose gives reactions very similar to those of glucose ; it reduces 
copper somewhat less readily (10 per cent.), ferments, and has an 
angle of lsevorotation of uncertain amount. Its characteristic test is 
that of Seliwanoff, which it is well to use in all cases of diabetes, yet 

67 Munch, med. Wochenschr., 1899, No. 50. 

68 Zeitschr. f. klin. Med., 1902, vol. xlvii. p. 182. 



THE HEINE 



185 



Rosin, also Fr. Miiller, 69 warn against the test, stating that it must 
he confirmed, since glucosamin gives the same. A moderately dilute 
hydrochloric acid (i volume of HC1 to 2 volumes of H 2 0) solution 
of resorcin is warmed and a little levulose added; the fluid at once 
becomes a beautiful red color, due to a precipitate which is soluble in 
alcohol. Levulose, if warmed with a concentrated alcoholic solution 
of resorcin, gives a brick-red color. It gives the- same osazone as 
glucose. It is a more fragile body than glucose. 

The other lsevorotatory bodies of the urine which must be excluded 
are albumin, glycuronic acid compounds, /?-oxybutyric acid, and cystin. 
If the laevorotation disappears on fermenting, the strong probability is 
for levulose. To be perfectly sure, the sugar must be isolated. 70 

Alimentary L^evulosuria has been much used as a test in the 
functional diagnosis of liver disease. Strauss 71 found that the inges- 
tion of 100 gms. of levulose was followed by lsevulosuria in 90 per 
cent. (26 of 28 cases) of cases with hepatic trouble, and in but 
10 per cent. (6 of 58) of normal men. Ferrannini and Bruining 
also considered the test valuable. Landsberg 72 could get the test in 
but 9 of 21 cases (not severe ones), and in four of seven normal 
persons. He therefore doubts its value. 

Lactose is found in the urine of women during lactation, in which 
case stasis in the lacteal glands is the cause, and in that of patients who 
have been long on a milk diet. In feeding experiments it is present 
after the ingestion of 100 gms. as a rule. In diabetics Voit has 
found that if lactose be fed they excrete glucose, while in the case of 
lactating women the reverse is true. The amount present is usually 
small, but may be as high as 2 to 3 per cent. In the case of lactating 
women it has been found in the urine of 115 of 148 cases (Ney). 
Others report it in all cases. It reaches a maximum on the second 
to the fourth day after delivery. 

Lactose is dextrorotatory (52.5 0 ). Lactosazon crystallizes in 
small yellow prisms arranged in spheres and with a melting point of 
200 0 C. Its reduction tests are like those of glucose, but copper is 
reduced somewhat less actively, and silver nitrate (ammoniacal) is 
reduced in the cold. Nylander's test is positive. If a solution of 
lactose is boiled several hours with dilute mineral acid, the lactose is 
inverted to galactose and glucose. It does not ferment with ordinary 
yeasts, though some will ferment it without the production of C0 2 . 
Its presence is to be suspected when the copper and bismuth tests are 
positive yet somewhat slow, and the fermentation and phenylhydrazin 

69 Deutsches Arch. f. klin. Med., 1904, p. 1630. 

70 See Peligot method, Compt-rend., vol. xc. p. 153. 
71 Deutsch. med. Wochenschr., 1901, Nos. 44 and 45. 
72 Ibid., August 6, 1903. 



186 



CLINICAL DIAGNOSIS 



are negative. The urine should first be sterilized else the bacteria in 
the yeast and urine will split the lactose, giving a fermentable sugar. 
If the urine does not ferment, yet reduces copper, lactose or pentose 
may be suspected. 

Riibner's test is valuable. The urine is boiled with an excess of 
sugar of lead from three to four minutes, when the solution becomes 
yellow or brown. To the hot fluid is then added ammonia as long as 
the precipitate which forms will still dissolve. An intense brick-red 
fluid is obtained which settles later as a copper-red precipitate with a 
colorless supernatant fluid. This test is positive if the lactose be from 
0.05 to 0.02 per cent. The test is perhaps best performed by adding 
3 gms. of PbAc to 10 cc. of urine. The precipitate is then filtered off 
and the filtrate tested. If the specific gravity of the urine be over 1020 
it is best to dilute one-half. If the test be performed as recommended 
tor glucose, that is, the solution warmed but not boiled, no red color 
is obtained — only a yellow coffee-brown or red, according to concen- 
tration. Glucose gives a red solution with a yellow precipitate. Mal- 
tose, a little yellow, and levulose. no color at all. To prove that it is 
lactose present the sugar can be isolated. 73 

Pentoses. — The pentoses, sugars with a chain of five carbon atoms, 
occur widely in nature, not as such, however, but as products by hy- 
drolysis of more complex carbohydrate molecules, which are very 
important in the vegetable kingdom. In the herbivora the pentoses 
play almost the same role as the hexoses in man. being glycogen- 
builders. In the animal kingdom they play an important part as the 
carbohydrate nucleus in the nucleo-proteid molecule of certain organs, 
the pancreas, thyroid, thymus, brain, spleen, and liver. 

Three types of cases are separated (Janeway). The first type, 
or alimentary pentosuria, occurs in all normal persons after the inges- 
tion of considerable amounts of fresh fruit juice, or of beer. In 
these cases the- pentose is always optically active. These sugars, when 
ingested pure, pass the easiest of all into the urine, and in the case 
of xylose may be demonstrated even after a dose of 50 mg. The 
diabetic pentosuria is rare. This occurs in very severe cases of 
diabetes whose inability to burn sugars extends also to pentose (Kulz 
and Vogel found pentoses in the urines of 64 of 80 cases). 

Ideopathic pentosuria is a quite different condition, first reported 
by Salkowski and Jastrowitz in two cases of suspected glycosuria. 
In 1902 the number had reached only five or possibly six (Brat's 
case 74 ). Bendix later collected twelve cases and adds one. It is 
interesting that several were old morphia habitues, but the pentosuria 
continued after the habit was cured in one case not in another. 

f3 See Hofmeister, Lehrb. d. Physiol. Chem., 1899, p. 519. 
74 Munch, med. YVochenschr.. 1903. 



THE UKIKE: PENTOSURIA 



187 



Janeway (Am. Jour. Med. Sc., Sept., 1906) collected twenty-two 
and added two. These two were brothers. It seems to be a chronic 
condition and without symptoms, the sugar being an accidental dis- 
cover}-. Pentose is not found in large amounts — in Salkowski's case 
it corresponded to from 0.07 to 0.15 per cent, of xylose, in Bendix's 
case, from 0.4 to 0.6 per cent. Rial 73 found that such cases could 
assimilate glucose normally, but pentose as well. The only explana- 
tion, therefore, that he- can offer is* that amexcess of pentose is formed. 
Bial also found the assimilation limit for hexose- and pentose normal. 

These urines reduce copper, but not well, as if only a trace of glu- 
cose were present. The reduction does not come at once, but after 
cooling, and suddenly throughout all the urine; they do not ferment, 
the urine is but slightly dextrorotatory, and with Nylander's. the pre- 
cipitate is only a gray. It is seen that they resemble the urine of lac- 
tosuria. V. Jaksch found that diabetics excreted from 48.98 to 82.02 
per cent, of the arabinoses of the food, and non-diabetics 1 to 46.65 
per cent. Non-diabetics excrete from 54.8 to* 18.7 per cent, of xylose, 
while diabetics only a trace. Of rhamnose from 63 to 55 per cent, 
was excreted by non-diabetics, and from 3 to* 13 per cent, by diabetics. 

Xylose is one of chief general importance. This is dextrorotatory. 
It forms osazones with a melting point of 159 0 to 160 0 C, reduces 
copper and Nylander's solutions, and gives an orange precipitate with 
Riibner's test; the furfurol reaction is positive; it does not ferment. 

The arabinoses are somewhat different. These are dextrorotatory 
(104 to 105 per cent.), reduce somewhat better than xylose, form 
osazones, the melting point of which is from 157 0 to 158 0 C. Other- 
wise they are very similar to the above. The inactive arabinose is of 
particular interest, since this is the sugar found in the ideopathic cases. 

Tests. — The pentoses give the phloroglucin reaction (as do also 
lactose and galactose), but with pentose the color test is confirmed by 
its characteristic spectrum, which is also true»of glycuronic acid, which 
gives exactly the same test. This test, according to Tollen, is as fol- 
lows ; To a few cubic centimetres of urine are added an equal part of 
HQ (sp. gr. 1. 19), then from 25 to 30 mg. of phloroglucin, and the 
solution warmed until a red color appears. This solution is examined 
spectroscopically at once for a band in the green. 

Salkowski recommends the following modification ; Five to six 
cc. of fuming HC1 are wanned and saturated with phloroglucin, leav- 
ing some undissolved. This solution is then halved. To the one test- 
tube is added 0.5 cc. of the suspected urine, and to the other 0 5 cc. 
of normal urine. Both test-tubes are then placed in a beaker of boiling 
water. If pentose be present, this tube will soon present a red color, 
which begins above and extends downward. The solution is exam- 

75 Verh. d. XIX. Kongr. f. inn. Med. 



188 



CLINICAL DIAGNOSIS 



ined spectroscopically. The test-tubes should be removed from the 
water-bath as soon as the red begins to appear. 

To exclude glycuronic acid the osazone must be determined (Sal- 
kowski). Two hundred to 500 cc. of urine are placed in a 
beaker, and 2.5 gms. per 100 cc. of urine of phenylhydrazin dissolved 
in an excess of acetic acid added (or 3.5 gms. HQ phenylhydrazin 
with 1.5 parts of NaAc). This fluid is then warmed until boiling 
begins. It is allowed to stand from one to one and one-fourth hours in 
boiling water and then cooled. If pentose be present in any consider- 
able amount, a large sediment of crystals will appear. As soon as the 
crystallization is complete the precipitate is then recrystallized from a 
hot, very dilute alcoholic solution, and again until the melting point is 
constant. 

The orcin-HCl test is recommended as a more specific one, exclud- 
ing the glycuronic acid compounds. To the urine is added an equal 
volume of concentrated HQ, and then a small amount of orcin. The 
solution is then heated. If pentose or glycuronic acid is present, the 
fluid becomes a reddish-blue color with a characteristic absorption 
spectrum. The urine should first be decolorized with animal charcoal. 
The reddish color may not be seen, or only very transitorily, a green 
color being obtained. The solution is cooled until only warm, and then 
shaken out with amyl alcohol. A green fluid with characteristic 
absorption bands is obtained. 

Bial's last modification of the Salkowski-Blumenthal test 76 is as 
follows: A reagent (HQ 30 per cent., 500 cc. ; orcin, 1 gm. ; 10 
per cent. Fe 2 Q 6 , 25 drops) is used. Four or 5 cc. of this reagent are 
heated to boiling, then removed from the flame and the suspicious urine 
added drop by drop, but not exceeding 1 cc. A fine green color appears 
at once, or very soon, if pentose be present. This test, he says, is not 
given by the glycuronic acid compounds or any other body but pentose. 
He considers his several critics now answered. 

If hexoses be present, these should not be fermented, since the 
pentoses, although unfermentable, will disappear during the process 
(attributed to the bacteria with the yeast). These sugars should be 
precipitated as osazones, and then separated. 

Method of Kulz and Vogel. — From 1.6 to 3.2 litres of urine are used. For 
each 100 gms. of glucose are added 200 gms. phenylhydrazin plus 100 gms. glacial 
acetic acid. The urine is then heated on a water-bath for an hour and a half, 
cooled, and filtered. The nitrate is again heated on the bath for one and a half 
hours and filtered. The combined precipitates are well washed with cold water 
and digested in water at 6o° C, which dissolves the pentosazone. Glucosazone is 
dissolved only on heating to boiling. One litre of water per 100 gms. of sugar is 
used, and the digestion continued twelve hours. This is repeated fifteen times. The 
hot extracts are filtered, then allowed to cool, and the pentosazone will separate. 
This is repurified, using less water, till the melting point is constant. 

76 Deutsch. med. Wochenschr., July 2, 1903. 



THE TJEINE 



189 



To separate the pentoses the alcoholic solution is polarized. The zylosazone 
shows a strong constant lsevorotation, while arabinosazone immediately after for- 
mation is dextrorotatory and then optically negative. 

Cases of pentosuria are exceedingly rare, perhaps because unsus- 
pected and therefore overlooked. This is the only sugar which, with 
many of the glucose tests, promises much trouble. Suspicious cases of 
glycosuria, in which the tests are unsatisfactory, should always be 
further examined. 

Inosite. — Inosite occurs in a great many plants and vegetables. It 
occurs rarely and in small amounts in the urine of nephritics and dia- 
betics, and also in other cases of polyuria. Naunyn mentions a case 
with 1 8 to 20 gms. per day, but emphasizes the fact that inosite is not 
a sugar, and the case was probably diabetes insipidus. Hoppe-Seyler 
considers that it occurs in all normal urines. The method of isolation 
and detection is rather long. We give it, since in other conditions also 
inosite is interesting. 

The urine should be evaporated to one-quarter its volume. The urine is then 
precipitated with baryta water. The precipitate is washed, decomposed with H 2 S, 
and evaporated (albumin must first be removed). After decomposition with 
H 2 S the filtrate is allowed to stand and the uric acid first filtered off. The 
filtrate is then concentrated to a syrup and treated boiling hot with two to three 
volumes of alcohol. A precipitate rapidly forms. This is cooled, ether is added, 
and the crystals will slowly appear. These are to be purified by decolorization 
and recrystallization. 

Tests. — The inosite is evaporated with nitric acid on a platinum- 
foil to dryness. To the residue are added a little ammonia and one 
drop of CaCl 2 . It is then again evaporated to dryness and a fine rose- 
red residue obtained (Scherer's test). This succeeds only when the 
inosite is fairly pure. 

Seidel's Test. — This is the same as the above except strontium 
acetate is added instead of CaCl 2 , and a fine green colored solution with 
a violet precipitate appears. This test is positive when 0.3 mg. of 
inosite is used. 

Gallois Test. — The inosite solution is evaporated almost to dryness, 
the residue moistened with a little mercuric nitrate. On drying the 
solution a yellow residue is obtained, which on high heat is of a fine 
red color, which disappears on cooling and reappears on warming. 

Glycogen (or Erythrodextrin). — This has been found in the urine 
of diabetics after the sugar disappears or diminishes as a dextrin-like 
substance which browns on the addition of iodine. The urine reduces 
copper after long boiling. To detect, the sugar is evaporated to a 
syrup, and KOH and absolute alcohol added until a cloud due to the 
potassium salts is obtained. The fluid is then decanted, the precipitate 
is washed several times with absolute alcohol, dissolved in acetic acid, 



190 



CLIXICAL DIAGNOSIS 



and reprecipitated with absolute alcohol. This precipitate is warmed 
with the alcohol and dried. A white tasteless powder is obtained, 
soluble in water, which reduces copper slowly and browns on the 
addition of iodine. 

Animal Gum (Landwehr). — This is said to occur normally in the 
urine. It seems to be a pentose, is slightly dextrorotatory, and not fer- 
mentable. With the copper test is obtained a precipitate which on 
boiling does not blacken. Alfthan found it much increased in diabetes 
mellitus (1.2 to 36.9 gms. per day, normally 0.1 to 0.2 gm.). It is 
probably not one, but a group of bodies precipitable by alcohol. 

Laiose is a sugar not yet well isolated and the nature of which is 
uncertain, found by Leo 77 in the urine of some diabetics. It is laevoro- 
tatory, non-fermentable, with a salty taste and little reducing ability 
except after long boiling. It gives an oily compound with phenylhy- 
drazin. It is not always present. 

Maltose was present in two cases, but in small and variable 
amounts. 

Isomaltose. — This sugar has been demonstrated in normal urine. 
Whether preformed or formed from glucose is uncertain, since the 
latter transformation is very easy. The osazone is in very fine crys- 
tals, with a melting point of 150 0 to 153 0 C. It does not ferment, or 
only very slowly, reduces copper and bismuth, and is dextrorotatory. 
It is to be demonstrated as a benzoate. 

Melituria. — In the case of some malingerers it may be necessary to 
recognize this sugar. 78 In Brown's case the urine was of high specific 
gravity, gave a positive Fehling's test, but not quite typical, and but 
very few crystals with phenylhydrazin. It fermented but very slowly, 
and was dextrorotatory. There may, therefore, have been a trace of 
glucose present or some of the cane-sugar inverted in the acid urine. 
The urine may be concentrated, boiled with dilute HC1 for from twenty 
to forty minutes, neutralized with sodium bicarbonate, after which the 
typical tests of glucose plus levulose (polarization therefore zero) may 
be obtained. 

Acetone. — Acetone occurs in all normal urines, the maximum nor- 
mal amount being about 10 mg. in twenty-four hours. It is much 
increased, according to V. Jaksch and others, in the following con- 
ditions : 

( 1 ) Alimentary. Acetone is increased whenever the carbohydrates 
of the diet are limited. It is always increased on a rich proteid diet in 
normal persons, and hence during hunger. It is also produced by a 
rich fat catabolism, but it requires about 150 gms. to influence the 
output. 

77 Virchow's Arch., 1887, vol. cvii. p. 108. 

™ Brown, Johns Hopkins Hosp. Bull., May, 1000, p. 101. 



THE UIUNE 



191 



(2) Febrile acetonuria. This is the most common pathological 
occurrence. It may occur with any fever, even light, and has no clin- 
ical importance. 

(3) Diabetes. In this condition it occurs in the largest amounts, 
and means an advanced or long-standing case. It usually also means 
a severe case, yet to this there are exceptions, and its presence need not 
necessarily mean an unfavorable prognosis. Yet its presence should 
be watched, as it is some criterion of the acidosis, and both therapy 
and diet will be in some degree determined by the depth of the test. 
More than 5 gms. may be excreted daily. Great rises may follow 
slight fevers ; it is decreased by alkalies ; it may be reduced by adding 
carbohydrate to the food, and yet in diabetes its output does not depend 
alone on the diet, although fat may yield some. In diabetes it tends 
to increase toward death and in coma. It is present also in the breath, 
giving it a fruity odor, 150 mg. even being excreted in one hour 
through the lungs. 

(4) Carcinoma cases in which inanition is not yet present. (5) 
Cases of inanition and cachexia. (6) Psychoses and lesions of the 
central nervous system, especially those associated with starvation. 
(7) Autointoxication. (8) Digestive disturbances, especially gastric 
ulcer. (9) Chloroform narcosis, in which case it is due to the in- 
creased proteid catabolism. (10) Pregnancy with a dead foetus. 
(11) Certain poisons: e.g., phloridzin. (12) Extirpation of the 
pancreas. 

In most of these cases there is little doubt that its source is proteid. 
Others claim (Schwarz) that it may also be formed from fats. The 
immediate mother substance of the acetone is probably diacetic acid. 

Acetone, CH 3 COCH 3 , is a thin, colorless fluid of a specific gravity 
of .814 (at o° C), and a boiling point of 56.5 0 C, with a quite 
characteristic odor. 

Tests. — The urine must be examined fresh. In almost all acetone 
tests the distillate of the urine is tested. From 250 to 1000 cc. of 
urine are used and a little acid, preferably phosphoric, added to pre- 
vent foaming. V. Jaksch advises that it be distilled with steam, in 
which case no acid need be used. A good cooler should be used, 
especially for quantitative work, although practically this is not neces- 
sary. Most of the acetone will pass over in the first 10 to 30 cc. Since 
diacetic acid is split up to acetone the urines should first be made alka- 
line and carefully shaken out with ether which is alcohol-free, if it is 
desired (as it seldom is) to exclude this body. This ether extract may 
then be shaken out with water and the latter tested for the diacetic 
acid. 

As a preliminary, Legal 's Test is recommended, and yet this is sat- 
isfactory only when large amounts are present. A negative report 



192 



CLINICAL DIAGNOSIS 



should never be made unless the more delicate tests are tried with the 
distillate. To the urine or distillate, better the former, are added a few 
drops of fresh concentrated sodium nitro-prusside solution, and then 
KOH or NaOH until very alkaline. A ruby-red color is obtained 
which changes rapidly to yellow. The test thus far is also given by 
creatinin, hence while the fluid is still red glacial acetic acid is added 
in excess. If acetone is present the red color will change to a purple- 
red, and later to violet. Creatinin does not give this color change, but 
a yellow changing to green and finally to blue. Paracresol gives a 
reddish yellow solution ; acetic acid a clear rose color. It is given 
by diacetic acid as well. In place of KOH, Le Noble and Lee used 
NH 4 OH to exclude aldehyde. 

Gunning's Test is very satisfactory. To the distillate is added tinc- 
ture of iodine or Lugol's solution (KI 1.8, I 1.2, H 2 0, q. s. ad 30), 
then ammonia until a deep black precipitate forms, which later grad- 



ually disappears, leaving a yellow sediment of iodoform. This sedi- 
ment is recognized by its color, odor, and microscopically by the six- 
sided tablets or stars. The sediment is seldom amorphous. In case 
of a trace it may be necessary to wait twenty-four hours. If necessary 
the sediment may be recrystallized from ether. This test may be 
applied to the urine directly, and is perhaps the safest clinical test 
for this purpose. Triple phosphate crystals are then also precipi- 
tated, and must be recognized. Gunning's test is less delicate than 
( Lieben's, but is given by no other body than acetone. It shows 0.0 1 
mg. per 1 cc. 

Lieben's Test. — To the urine or distillate are added a few drops of 
KOH, and then Lugol's, and the solution warmed. Crystals of iodo- 
form will form. This test will show 0.0001 mg. in twenty-four hours, 
0.0 1 mg. in from two to three minutes. It is the most sensitive but 
less specific than the above, since alcohol and aldehyde give it. 




Fig. 28. — Iodoform crystals formed from the distillate of the urine of a case of diabetes. 



THE URINE 



193 



Folin (Jour, of Biol. Client., May, 1907; Jour, of A. M. A., 
May 2, 1908) has recently upset a few of the generally accepted 
ideas concerning acetone. He finds that the amount of acetone in 
the urine of even severe cases of diabetes is very small indeed ; that 
the most of the substance estimated as acetone is diacetic acid; that 
some of the tests, e.g., Legal' s, supposed to show acetone are really 
very delicate tests of diacetic acid ; and that the odor of the diabetics' 
breath and urine may be fruity, but this odor is not due to acetone. 

Quantitative Determination of Acetone and Diacetic 
Acid — The Huppert-Messinger Method. — This method deter- 
mines the sum of acetone and the diacetic acid which is transformed 
to acetone by the distillation. 

The solutions necessary are : 

1. Acetic acid, 50 per cent. 

2. N/10 iodine solution. 

3. N/10 sodium thiosulphate solution. 

4. A thin starch solution ( 1 gm. of starch dissolved in 500 cc. of 
boiling water). 

To make up these solutions 24.8 gm. of crystallized sodium thiosulphate 
(NaoSaOs + 5H2O) are carefully weighed, dissolved in distilled water, and the 
solution made up accurately to one litre. Next 25 gm. of potassium iodide are dis- 
solved in a little water, 12.7 gm. of iodine added, and the solution made up to about 
900 or 950 cc. To standardize this solution 20 cc. of the thiosulphate solution are 
carefully measured into a small flask, a few drops of the starch solution added, 
and then the iodine solution added from a burette with glass stop-cock until the 
blue color just appears. This titration is repeated several times until the amount 
necessary for the end reaction is accurately determined, then to the iodine solution 
is added the necessary amount of water so that 20 cc. of this solution will exactly 
equal 20 cc. of the thiosulphate solution. This dilution should be confirmed by 
an additional titration. 

Both of these fluids are to be kept in dark glass bottles with ground glass 
stoppers. The iodine solution must be restandardized frequently. One cubic 
centimetre of the thiosulphate solution equals 0.0127 gm. of iodine. The formula 
of the reaction is 2I -j- 2Na 2 S20 3 = 2NaI + Na 2 S4O 0 . The first free iodine in excess 
will form the blue starch iodine compound. 

The urine if alkaline is first just acidified with acetic acid. To 
500 cc. of acid urine (if rich in acetone, e.g., a febrile urine, 100 cc. 
or even less) is added 50 per cent, acetic acid, exactly 2 cc. per 100 
cc. of urine. The urine is then distilled until only about one-tenth 
the volume remains. The flask receiving the distillate is tightly closed 
by a stopper with two perforations. Through one of these passes the 
tube from the distilling flask, and this tube reaches to the bottom of 
the flask and dips below the surface of water previously placed there; 
through the other passes a shorter tube connected with a bulb or Peligot 
U-tube filled with water, which acts as a safety bulb to prevent the 
loss of any of the very volatile acetone. This receiving flask is, dur- 
ing the distillation, surrounded by ice. When the urine is distilled 
& 13 



194 



CLINICAL DIAGNOSIS 



down to about one-tenth its original volume the distilling flask is dis- 
connected before the heat is removed, else the distillate will " strike 
back." The tube of the cooler is then washed through with distilled 
water to wash into the receiving flask the last trace of distillate. The 
water in the safety bulb or U-tube is emptied into, and the tube washed 
and this water added to the distillate. 

Some calcium carbonate is then added to the distillate and this well 
shaken. This is to remove any nitrous and formic acid which may 
have distilled over. The distillation is then repeated as before. 

To this second distillate (to which is again added the water in 
the safety tube and the wash-water from both tubes) is added i cc. 
of dilute sulphuric acid (1:8 of water), and the distillation again 
repeated. 

This final distillate is poured into a flask or measuring cylinder 
with ground glass stopper. (Or indeed this flask or cylinder may be 
used to receive the distillate during the distillation. It is of course 
protected as in the first distillation.) A large excess of carefully 
measured N/io iodine solution is added, these fluids well shaken, 
and then an excess of strong nitrite-free NaOH or KOH added drop 
by. drop. The flask is closed, shaken for one-quarter of a minute 
and then allowed to stand for five minutes. The vessel used must 
be so large that its contents will now not more than one-third fill it. 

The stopper is then removed (and all fluid clinging to it washed 
back into the flask), the contents of the flask is then made acid with 
concentrated hydrochloric acid, and the excess of iodine determined 
by titration. The N/io thiosulphate solution is added from a burette 
until the mixture is only slightly yellow, then a few cubic centimetres 
of the starch solution are added and the addition of thiosulphate 
solution continued until the blue color just disappears. If a little 
too much thiosulphate is added one adds a measured amount of iodine 
and continues the titration till the end reaction is reached. One cubic 
centimetre of the iodine solution equals 0.967 mg. of acetone. 

The results of this method are from 4 to 8 per cent, too low. The final distillate 
must contain no phenol nor ammonia nor nitrous nor formic acids, for all of these 
but nitrous acid will cause the loss of some iodine while that will set iodine 
free. In this method the error from ammonia is prevented by the addition to 
the just-acid urine of 2 cc. of acetic acid per 100 cc. of urine. If a mineral 
acid, or 5 cc. of acetic per 100 cc. of urine were used none of the ammonia would 
reach the distillate but some phenol would. For this reason only 2 cc. of acetic 
per 100 cc. of urine are added and the trace of ammonia which does distil over 
is later removed by the third distillation after the addition of sulphuric acid. The 
addition of calcium carbonate to the first distillate will remove the nitrous and 
formic acids. 

It is wise to add the alkali and the iodine solution to the final distillate without 
shaking much and to notice whether the fluid separating these two partial layers 
turns at all black. If so ammonia is present and the specimen should be thrown 
away. If none is indicated the fluid is shaken, etc. 



THE HEINE 



195 



An easier and fairly satisfactory determination may be made as 
follows : 

From 50 to 250 cc. of urine are distilled until the great mass of 
water is passed over. To the end of the tube, which should have a 
good cooler, is attached a rubber tube, the end of which dips into w:ater 
in the receiving flask. A little acid may be added to prevent foaming. 

The distillate is poured into a graduated cylinder with a ground 
glass stopper, an excess (15 to 20 cc.) of NaOH added, and then 
20 cc. of Lugol's, which is conveniently made three times the ordinary 
strength. A heavy black precipitate forms which soon clears, leaving a 
yellow sediment of iodoform crystals. After standing for some time, 
ten to fifteen minutes or more, about 40 to 50 cc. of ether are added 
and the fluid shaken out until the ether contains all of the iodoform 
A reading is then made of the volume of ether, 10 cc. are removed in a 
graduated pipette and evaporated in the air in a weighed glass dish. 
This is then dried over sulphuric acid and the dish again weighed. 
The weight of the iodoform multiplied by O.147 equals the weight 
of acetone represented in the number of cubic centimetres used. That 
of the whole ether extract may then be reckoned. 

The above method gives the sum of the acetone and diacetic acid 
in terms of acetone. Folins method {The Jour, of Biol. Chem., May, 
1907) is the only one which allows an estimation of the acetone alone. 
The acetone is separated from the urine by the apparatus which 
Folin has introduced for ammonia estimations (see page 126). 
Twenty-five cubic centimetres of urine are measured into the aer^ 
ometer cylinder, from 0.2 to 0.3 gm. of oxalic acid or a few drops 
of 10 per cent, phosphoric acid, and 8 to 10 gm. of sodium chloride 
and a little petroleum are added. In the absorbing bottle has been 
placed water to which is added 40 per cent, potassium hydroxide 
solution (10 cc. per 150 cc. of the water) and an excess of the 
standardized iodine silution. The apparatus is then connected with a 
Chapman air pump and a fairly strong (yet not so strong as for an 
ammonia determination) air current drawn through for 20 or 25 
minutes. Every trace of acetone will be removed from the urine 
and converted in the receiving bottle to iodoform. The contents of 
the receiving bottle are acidified with concentrated hydrochloric acid 
(10 cc. for each 10 cc. of alkali used) and the excess of iodine 
titrated with standard thiosulphate solution and iodine as in the 
Messinger method. The observer must be thoroughly acquainted 
with his air current and apparatus by repeated experiments with pure; 
acetone. 

Diacetic Acid. Acetoacetic Acid, CH 3 COCH 2 COOH.— Diacetic 
acid is the most important, from the clinical view-point, of the acetone 



196 



CLINICAL DIAGNOSIS 



bodies, since it is much the easiest to test for, and would seem to pre- 
dominate in amount. It should always be tested for in diabetes, since 
its presence in large amount is the best indication of a severe acidosis. 
The present idea is that all diacetic acid is derived from /?-oxybutyric 
acid, and that all the acetone in the urine is in turn derived from 
diacetic acid. Only a trace, if any, is normal in the urine, and prob- 
ably none if the person is on a mixed diet. It appears quite early in 
the urine of a person on starvation diet, or on a diet poor in carbohy- 
drates, and promptly disappears, if even a little carbohydrate b r e added 
to the diet. But the differences between individual cases in this par- 
ticular are so great that its presence cannot be due to lack of carbo- 
hydrate in the diet alone. The statement usually made is that it 
occurs only when acetone is present in large amounts, but not always 
then. Nevertheless, the recent work of Folin would seem to prove 
that acetone is present but in traces, and that the most of the substance 
which we call acetone is diacetic acid. Since it is the mother-substance 
of acetone-, its list of occurrences is practically the same as that of 
the latter. In most cases with much diacetic acid oxybutyric acid is 
probably also present, but the latter is more difficult to- determine. 

In most cases the cause of the appearance of diacetic acid in the 
urine is undernutrition or the failure of absorption, and hence occurs 
in all cachexia-'producing diseases. It occurs in certain fevers, espe- 
cially in the acute exanthemata of children during the eruptive stage, 
even in mild cases. Its occurrence- and amount- would seem to depend 
much on the. nature of the infection, and the streptococcus infections 
seem especially favorable for its production. Its presence here is not 
at all limited to the febrile periods. In these cases it has no prognostic 
importance. It occurs with the greatest frequency in gastro-intestinal 
disturbances, even when mild, and is not due merely to the lack of 
carbohydrate, for it does not disappear when this is administered, as 
promptly as in health and on a pure proteid diet. In such cases it 
would seem to depend on abnormal fat catabolism. It is said to occur 
in especially large amounts in the urine of drunkards with gastro- 
intestinal disturbances. Rolleston and Tebbs 80 found it present in 
large amounts in 33 of 38 cases of gastric ulcer treated either by 
starvation or by rectal feeding, the test appearing in from two to 
twelve days, usually one to two days, after treatment begins, and 
disappearing in from one to fourteen days, usually the fifth, after 
mouth feeding is begun. Women especially showed the test ; age and 
chronicity of disease seemed of no moment. In some cases the 
output of ammonia (index of acids) is as great as in diabetes 

79 See Neubauer and Vogel, p. 760. 

80 Brit. Med. Jour., 1904, vol. ii. p. 114. 



THE UKINE 



197 



(Golla). It may be found in the urine of normal men who have been 
for some days on a pure proteid diet, and in mental cases with loss 
of weight and inanition. 81 

Gerhard fs Test. — This very important test is best applied as fol- 
lows : To 10 to 50 cc. of urine are added a few drops of Fe 2 Cl 6 solu- 
tion, which must not be too acid. This is added as long as a precipitate 
forms, and then the urine filtered. To the filtrate is added still more 
Fe 2 Cl 6 . If diacetic acid be present, the urine takes on a Bordeaux-red 
color, cherry-red by transmitted, purple-red by reflected, light. The 
test indicates from 0.4 to 0.5 p.m. of diacetic acid. Cyanates, NaAc, 
salicylic acid, its allied bodies, salol, aspirin, diuretin, and certain other 
bodies also will give it. The colors obtained are not just the same, 
with strong solutions not at all similar, yet by adding various amounts 
of reagents, exactly the same color, it is said, can be produced, hence 
the test should always be controlled by boiling the weakly acid urine 
and repeating the*test after the urine has been cooled. The red should 
be fainter, since wie diacetic acid has in part been decomposed, but to 
boil half an hour, will not break it all up. The urine may be acidified 
with H 2 S0 4 , shaken out with ether, this with water, and the Fe 2 Cl 6 
added. A violet-red color is seen in the water layer. The color pales 
in from twenty-four to forty-eight hours on standing, a necessary part 
of the reaction to exclude other bodies. The urine should always be 
tested fresh. 

Riegler's test has been much criticised, and its negative nature is unsatisfac- 
tory. In its latest 'modification 82 15 cc. of urine are mixed with 2 cc. of 10 per 
cent Jodsaure and 3 cc. of chloroform and shaken. If diacetic acid be present, 
the chloroform remains colorless, otherwise it takes up a violet color. 83 

/?-Oxybutyric Acid, CH 3 CHOHCH 2 COOH.— This is the mother- 
substance of diacetic acid and hence of acetone. It may, therefore, be 
looked for when, diacetic acid is present in large amounts, but not 
necessarily fount}, since it breaks up to diacetic acid and acetone so 
rapidly. Its list of occurrences is the same for acetone except it is 
found much more rarely. This acid occurs in the urine of non- 
diabetics; scurvy, severe infectious diseases, starving insane persons, 
but these are all in malnutrition. Gerhardt has shown that it is present 
in the urine of a normal man after some days on a pure proteid diet 
(about 9 gms. in twenty-four hours were found). 84 This acid is of 
extreme importance, since to its acid intoxication (a better term is 
alkali starvation) is attributed the coma. If it once begins, the ten- 
dency is for it to increase ; often about 50 gms. a day are excreted, and 

81 See also Futcher, Med. News, October 8, 1904. 
^Zeitschr. f. klin. Med., 1904, Bd. 54. 

83 For criticism, see Voltolini, Zeitschr. f. klin. Med., 1903, Bd. 48, p. 336. 

84 Gerhardt and Schlesinger, Arch. f. exp. Path. u. Pharm., 1898. 



198 



CLINICAL DIAGNOSIS 



in one of Naunyn's cases 100 gms. a day for a long time. Whether 
oxybutyric acid is toxic because of its acid nature alone, or has a 
specific toxicity is in doubt, the Strassburg school holding the former 
idea. Wilbur, 85 from animal experiments, injecting the neutralized 
acid, found the results similar to those of the free acid. He remarks 
that the alkaline treatment is not as satisfactory in coma as one would 
from theoretical grounds expect. Larger amounts are reported — even 
1 88 gms. in twenty-four hours (Magnus-Levy) ; Kiilz, 225 gms.; and 
Joslin's case, 437 gms. in three days, — i.e., 3 gms. per 1 K per day. 

This acid is laevorotatory, — [a] D = — 24.12 0 . Its presence, there- 
fore, is possible when the percentage of sugar measured with the 
polariscope is less than that by titration. The presence of other lsevo- 
rotatory bodies should always be considered, levulose, paired glycuronic 
acid compounds, albumin, etc. 

Detection. — It is probably present if the fermented urine of a 
diabetic shows some laevorotatory body. It is quite surely present if 
the ether extract of urine first fermented, then acidified wth phos- 
phoric acid, and then extracted with ether, is laevorotatory. 

The urine may be fermented, evaporated to a syrup, and an equal 
amount of concentrated H 2 S0 4 added. This is then distilled directly, 
and crotonic acid is obtained. The distillate cooled gives beautiful 
crystals with a melting point of 72 0 C. If these crystals do not readily 
form the distillate may be shaken out with ether, the ether evaporated, 
the residue washed with water and allowed to crystallize. 

For two valuable unpublished methods I am indebted to Dr. Otis F. Black. 

Black's Qualitative Test for /3-Oxybutyric Acid. — The test depends on the 
oxidation of j3-oxybutyric acid to acetacetic acid in the presence of ferric chloride, 
giving the well known color reaction. From 10 to 15 cc. of urine are concentrated 
in a small evaporating dish at a gentle heat to a few cubic centimetres, thus getting 
rid of the acetacetic acid, if present. The residue is acidified with one or two 
drops of concentrated hydrochloric acid and made to a thick paste with plaster of 
Paris. This is stirred and pulverized as it sets, with a blunt stirring rod, and the 
mass stirred up and decanted twice with ether. The ether is evaporated and the 
residue taken up with water and neutralized with barium carbonate. To the solu- 
tion thus obtained in a test tube is added one or two drops of hydrogen peroxide 
and a few drops of a 5 per cent, solution of ferric chloride containing a trace of 
ferrous chloride. The characteristic wine red or violet color appears immediately, 
or on standing a few minutes, if /3-oxybutyric acid is present. 

Quantitative Determination. — The methods proposed for determining this 
acid are several. A good clinical method is the difference between polarization 
and titration. Both must be accuratelv done. This is the best method, and in 
all severe cases is well worth the time. s<i Others, Schwarz, e.g., compare the result 
with Lohnstern's fermentation saccharometer with the polariscope. An easier 
method is the polarization of the fermented urine. The lsevorotation must remain 
after the urine has been cleared with basic lead acetate and ammonia. There is 
no certainty that no acid is destroyed. The method used by Magnus-Levy who 
determined all of the inorganic acids and all the bases, and supposed the differ- 

53 Jour. Am. Med. Assoc., 1904, No. 17. 

86 See Pavy, Lancet, 1902, pp. 64-143, 207, 347. 



THE URINE : DIABETES MELLITUS 



199 



ence to be due chiefly to this organic acid, is, we have very good reason to know, 
very laborious and does not seem to have proven particularly satisfactory. 

Bergell s7 recommends the following : From 100 to 300 cc. of urine, fermented 
if glucose be present, are made weakly alkaline with sodium carbonate and evapo- 
rated on a bath to a syrup. This is then cooled and the residue rubbed up with 
phosphoric acid, cooling it meanwhile, then with 20 to 30 gms. of fused finely 
pulverized CuS0 4 and 20 to 25 gms. of fine sand. This mass is well mixed. The 
dried mass is then put in a paper sac of the Soxhlet ether extraction apparatus 
and extracted with ether (which has been freed from water by the fused CuSCX) 
for one hour. (Black has devised a home-made ether-extraction apparatus which 
we believe is very superior to the usual form of Soxhlet apparatus, since any one 
can make it, and the substance to be extracted is in contact with hot ether.) 
It is then filtered and the Q1SO4 washed out with dried ether. The ether is then 
distilled off, the residue taken up by 20 cc. of water, decolorized with animal 
charcoal, and polarized. 

Black's Quantitative Method for /3-Oxybutyric Acid. — One hundred cubic 
centimetres or more of urine are measured into an evaporating dish, made faintly 
alkaline with sodium carbonate, and boiled down to one-third or one-quarter of 
the volume, then concentrated further on the water-bath to about 10 cc. 

The residue is cooled, acidified with a few drops of concentrated hydrochloric 
acid until it reddens litmus distinctly, and mixed with plaster of Paris to a thick 
paste. 

The mixture on standing a few minutes begins to harden. 

It is then stirred and broken up with a blunt glass rod, yielding a porous mass 
which is transferred to a Soxhlet apparatus and extracted with ether for two 
hours. The ether extract is evaporated, the residue taken up with water and 
treated with a little bone black if necessary, filtered, and made to known volume 
(25 cc. or less). The amount of /3-oxybutyric acid is then determined with the 
polariscope. 

Darmstadter 88 proposes the following method : To 100 cc. of urine is added 
enough soda to make it weakly alkaline. It is then evaporated on the water-bath 
almost to dryness, and the residue is washed by 150 to 200 cc. of 50 to 55 per 
cent. H2SO4 into a i-litre flask. This flask is then connected with the cooler of 
a distilling apparatus. Through the cork of the flask also enters a dropping 
funnel. The flask is just heated by a small flame until foaming ceases, then 
strongly, water added little by little from the funnel as it distils away, until 300 
to 350 cc. of distillate have collected. This will take from two to two and one-half 
hours. The distillate is shaken out two to three times with ether, the ether 
residue heated a few minutes on a sand-bath at 160 0 C. to drive off the fatty acids, 
dissolved in 50 cc. of water, filtered, and the watery extract of crotonic acid 
titrated with tenth-normal NaOH, using phenolphthalein as indicator. One hun- 
dred cc. tenth-normal NaOH ==: 0.85 gms. crotonic acid. The amount of crotonic 
acid multiplied by 121 equals amount of oxybutyric acid, hence 100 cc. NaOH = 
1.0406 gms. oxybutyric acid. 

Boekelman and Bouma 89 propose the following simple method : 
To 25 cc. of urine in a flask are added 25 cc. of 12 per cent. NaOH, then 25 cc. 
of benzoylchoride ; the flask is corked and shaken hard under cold water for three 
minutes. The clear fluid is then pipetted off, filtered, and polarized. The benzoyl- 
chloride will clear the urine of carbohydrates, albumin, etc., leaving the acid the 
only lsevorotatory body. 

Diabetes Mellitus. — The urine in diabetes mellitus is, as a rule, in- 
creased in amount. This increase is often not marked unless there is 

87 Zeitschr. f. phys. Chem., 1901, xxxiii. 310. 

88 Zeitschr. f. phys. Chem., xxxvii. p. 355. 
88 Centralb. f. inn. Med., 1902, No. 25. 



200 



CLINICAL DIAGNOSIS 



over 2 to 3 per cent, of sugar, beyond which point it is roughly pro- 
portional to the amount of glucose present. In severe cases, that is, 
with 5 per cent, of sugar or more, there may be from 4 to 5 litres of 
urine and even io litres, whereas one case is on record with 28 litres 
in twenty-four hours. On the other hand, there are cases with a high 
percentage of sugar and small amounts ; two, for instance, reported 
by Naunyn, the one with 1400 cc, 9 per cent, of sugar, specific gravity 
1040 ; a second, 2700 cc, 10.5 per cent, of sugar, specific gravity 1047. 
In other cases the reverse is true, but this is rare except in those cases 
following injury to the skull, in which during the day the specific 
gravity may be as low as 1003 with 1 per cent, of sugar (Naunyn's 
case) ; also in beginning chronic interstitial nephritis, and when the 
patient is very weak. 

The urine has a high specific gravity, this being a condition with 
a high specific gravity and an increased amount of urine, but the 
specific gravity bears little relation to the latter. It is usually 1030 to 
1040. Naunyn's maximum was 1060, and he mentions a case reported 
with 1074. With a specific gravity of 1030 there is almost always a 
diuresis. 

The sugar is glucose, yet levulose and pentose and other carbo- 
hydrates are also present; in rare cases levulose alone. There is an in- 
crease also of the unfermentable carbohydrates (a minimum of 20 
gms. instead of 1.6 gms. ; normal maximum, 5 gms. per day). 90 

The urine is of a suggestive pale greenish-yellow color. It will 
ferment spontaneously, the fermentation resulting in the evolution of 
C0 2 and a sediment. This fermentation may occur in the bladder 
and a sugar-free urine be excreted ; again, the fermentation may give 
no gas. 

In testing the urine qualitatively for glucose it is important to 
choose the right specimen. In a severe case with sugar present at all 
hours this is not important, but in those mild cases with a very slight 
output, and for only a few hours after a rich carbohydrate meal, the 
sugar solution may in the whole twenty-four hours' specimen be so 
dilute that it escapes notice, while if the urine voided from two to 
four hours after a heavy carbohydrate meal be examined the test is 
clearly positive. It is well, therefore, to recommend to a suspected 
case a carbohydrate meal, preferably a breakfast, and examine the 
urine voided four to six hours later. It has been found that the maxi- 
mum excretion is in the late forenoon, even when the ingestion of 
carbohydrates extends over the whole day. There is another maxi- 
mum, somewhat less, in the late afternoon. Naunyn teaches that cases 
must be separated according to the percentage of the sugar excretion, 
the " intensity," and to the total amount of sugar excreted in a day, 

90 Edsall, Am. Jour. Med. Sci., 1901. 



THE UKINE: DIABETES MELLITUS 



201 



the " size." Cases can be compared in this way only when on a 
constant diet. 

In cases whose sugar excretion is continuous a minimum occurs 
late at night and early in the morning, a maximum late in the after- 
noon and at about 6 p.m. In severe cases the variation is little marked 
and much more may be excreted during the night than during the day 
(note resemblance to the excretion of water and solids in nephritis). 
In the light cases the urine may be sugar-free during the night and 
even reach 3 per cent, during the day. Some cases will be sugar- free 
for months and then have periods of glycosuria. It is thus seen that 
the mild cases may easily be overlooked in case but one specimen is 
examined. The output is greater in hot than in cold weather, which 
is true also of the carbohydrate of normal urines. 

The amount of sugar per day is often 800 gms., and in one case 
1500 gms. in twenty-four hours. Such outputs occur only when the 
patient is on a liberal diet. On a strictly proteid diet cases excrete 
seldom over 100 gms., very rarely 200 gms. 

As regards the relation between water and glucose excretion, dia- 
betics respond to an increased intake more slowly than do normal 
people. In general it may be said that the water excretion depends 
upon the glucose, although this is not true of the day and night 
variations. 

Influence of Diet. — The output is increased by a carbohydrate diet, 
especially dextrose and its polysaccharides. It is less influenced by 
levulose, lactose, and their polysaccharides. The starches of potato 
and oatmeal seem very well borne. If levulose, for instance, be fed, the 
sugar excreted is glucose, and yet a diabetic stands levulose quite well 
for a day or two, not longer. Lactose and cane-sugar are similarly 
treated. Fat causes no increase. Proteid causes a slight increase. In 
severe cases the output also varies with gastrointestinal troubles, which 
are so common in diabetics and which may prevent absorption of 
sugar. Muscle work decreases it, and psychical influences, such as 
fright, mental strain, or worry, increase it much or bring a latent case 
to light. Hence in diabetics a peaceful mind is one of the essentials. 
Mendel and Lusk 91 found on a constant proteid-fat diet the constant 
ratio of glucose to nitrogen of 3.65: 1, that is, the same as in the 
phloridzin diabetes of dogs. 

They recommend this as a method of prognosis. The patient is put on a 
meat-fat diet (rich cream, meat, butter, and eggs), and the twenty-four hour urine 
of the second day is collected (the day ending to include the early morning urine). 
If N : glucose : : 1 : 3.65, it means the complete intolerance for carbohydrates and 
probably a quickly fatal outcome. 

Intensity of Glycosuria. — On a rich carbohydrate diet the percent- 

91 Deutsches Arch. f. klin. Med., 1904, vol. lxxxi. 



202 



CLINICAL DIAGNOSIS 



age rarely exceeds 6 to 8 per cent. Naunyn mentions a case of 1 1 per 
cent., while others mention a case with 20 per cent. 

The effect of acute infections is particularly interesting, since in 
pneumonia, for instance, there is a remarkable diminution in sugar 
output with even an increased tolerance to carbohydrates. This is not 
due to the diet, and begins with the rise of temperature. The 
explanation is not known. On the other hand the sugar may be 
increased during the fever, or be present during an intermission, or 
be found after the fever, hence the statement that the complicating 
disease has been the cause of the diabetes. 

Chronic diseases such as tuberculosis of the lungs, nervous dis- 
eases, circulatory disturbances with albuminuria, and nephritis tend 
to diminish the sugar output. As some diseases develop, and this is 
true of Bright 's disease especially, the glycosuria wholly disappears, 
and they are reported as cured. This is not due alone to the diet, 
since the tolerance to carbohydrates is actually increased. Neither is 
it due to the kidneys, since the percentage in the blood does not 
increase. It may be due to the cachexia sometimes present. 

The sugar output is subject to spontaneous fluctuations of con- 
siderable amount, even too per cent. These cannot be explained in 
any way except as variations in tolerance. 

Severity and Tolerance. — A light case is, according to Naunyn, 
one which can eat daily 60 gms. of bread and remain sugar-free for a 
long time. By " paroxysmal tolerance " he means one that can stand 
considerable carbohydrate and be almost sugar-free, and yet which it is 
impossible to> rid of that last trace. These are severer cases. The 
old rule that a light case was one which was sugar-free on a strict diet 
will not hold, since even a proteid diet is not sugar-free and severe 
cases may keep sugar-free for some time, and yet it be expensive for 
the body. There is a constant tendency for a large glycosuria to 
increase, and the greater the glucose output the weaker becomes the 
tolerance. The slight glycosurias tend to diminish. This tolerance 
suffers more from large amounts of glucose at one time than from the 
same amount in divided portions. The reverse is also true that toler- 
ance is increased more by a brief sugar-free period than by a longer 
period of moderate output, hence in treating a diabetic the value 
of the "hunger day.'' If by a total fast the patient is sugar-free 
for twenty-four hours, on the following day he will often be able 
to stand without any glycosuria an amount of bread which previously 
would have caused a marked rise. 

A case of transitory " diabetes " with acidosis is reported by 
Mann 92 which lasted sixteen days, then disappeared even though much 
sugar was consumed. 

92 Berl. klin. Wochenschr., 1904, No. 30. 



THE HEINE 



203 



Coma and Acidosis. — By " acidosis" Naunyn meant the production 
in the body by disturbed metabolism of acids in abnormal amounts 
sufficient sometimes to cause an acid intoxication, or, better expressed, 
an alkali starvation, resulting, it is believed, in the diabetic coma. 
The urinary symptoms of acidosis are the appearance of large amounts 
of acetone or diacetic acid, and, in severe cases, oxybutyric acid, prob- 
ably the mother-substance of the others. The production of these 
bodies is not characteristic of diabetic disturbances of metabolism, 
since a normal person on a sugar-free diet will in a few days produce 
them all. In diabetics there may be from 20 to 30 gins, of oxybutyric 
acid excreted daily for years. When an acidosis once begins the ten- 
dency is for it to increase. It is increased also by a rigid diet ; when 
the strict dietary treatment of diabetes was first practised the clinicians 
were surprised at the number of cases of coma, which resulted since 
the already partially poisoned organism was further burdened by an 
increase due to diet ; hence the value of making the patients sugar-free 
by rapid reduction rather than a reduction in carbohydrate extending 
over a long period of time. As coma comes on there is usually a 
sudden rise in these acid bodies, coma being preceded by days or even 
months with a daily output of 20 gms. or more of oxybutyric acid, 
but the output of 25 gms. indicates oncoming coma (Herter). The 
greatest increase follows the improvement in coma, for it is not the acid 
in the urine which causes the trouble, but the acid which has not been 
excreted. The presence of acidosis means usually a severe case, or at 
least an advanced case in which emaciation has begun, and yet the 
condition may exist for years. Patients with much acidosis die of 
coma unless from some intercurrent disease, and there is no case of 
true coma yet studied without a previous acidosis. The amount of 
these bodies is perhaps better estimated by the ammonia output than 
by their direct determination, since the symptoms are caused by a 
withdrawal of the body alkali which the ammonia protects. An 
increase of ammonia means the presence of at least 10 gms. of oxy- 
butyric acid per day, — a marked increase, about 15 gms., 4 gms. of NH 3 
indicating 16 gms. of the acid (Herter). Naunyn considers that over 
3 gms. of ammonia per day means danger of coma, and that if 4 gms. 
per day are excreted coma is sure to result unless alkaline treatment is 
begun at once, and then the end is only delayed. Coma was the 
terminal event of 18 of Naunyn's 44 fatal cases, the most of them 
young persons from twenty-one to thirty years of age. 

A sign, sometimes important, of coma, seen well in many cases 
and in one of ours, is the appearance of large numbers of granular 
casts giving a gross sediment. This may appear with the coma or 
give warning twenty-four hours in advance (Kiilz sign, page 276). 

Among the other urinary symptoms in diabetes is an increase in 



204 



CLINICAL DIAGNOSIS 



the outputs of the creatinin (even 2 gms. q. d.), uric acid, phosphoric 
acid, and sulphuric acid. In all of these conditions, however, the 
increase is due to the diet and not to the disease. Oxalic acid is also 
increased, especially as the sugar disappears (even 1.2 gms. per day). 
The animal gum of Landwehr is much increased. 

Albumin is quite often present. In Naunyn's cases of pure dia- 
betes 32 of 94 had albuminuria, 17 of whom showed occasional traces, 
6 long-standing traces, and 10 much albumin. Ruling out those cases 
in which the albuminuria is due to complicating diseases, Naunyn con- 
siders that there is a certain relation between diabetes and albuminuria 
resulting from the effect of glycosuria on the kidney. On the other 
hand, it is interesting that as a case of chronic nephritis develops, the 
glycosuria gradually disappears, and hence cases of the so-called 
" cures." In some cases the glycosuria and albuminuria may alternate. 

Diabetes Insipidus. — The cases from this clinic were recently re- 
ported by Futcher in the Johns Hopkins Hospital Reports. 

This is a very rare condition, Futcher reporting from this clinic 
but four cases, or 0.001 per cent, of admissions. It occurred particu- 
larly in young men. Jacobi considers, however, that fully 25 per cent, 
of the cases are -in children under ten years of age. The cases may be 
divided as primary or idiopathic, which cases have no known lesion, 
and the secondary or symptomatic. Such cases are the result par- 
ticularly of tumors of the base of the brain, trauma or hemorrhage, lues 
of the brain, and basilar meningitis. It is also symptomatic of certain 
diseases of the abdominal viscera and of the spinal cord. There is a 
polyuria sometimes present in the psychoses, particularly hysteria, epi- 
lepsy, and chorea, which in some cases would suggest diabetes in- 
sipidus. 

Polyuria is the only necessary symptom of the disease. From 
20 to 40 litres may be voided in twenty-four hours, and in one case, 
43 litres. In two cases of children the amount voided daily was 
almost equal to the body weight. The urine is pale, watery in color, 
faintly acid in reaction, and of exceedingly low specific gravity — from 
1000 to 1005. (It is exceedingly important in this disease that the 
temperature correction in the specific gravity determination be care- 
fully made.) In other cases there may be a polyuria with a normal 
specific gravity; e.g., 6 litres and 1017. Albuminuria and cylindruria 
are absent, this absence indeed being the important point to rule out 
chronic interstitial nephritis. 93 Sugar is also absent, and yet there are 
cases of diabetes insipidus which will develop into diabetes mellitus. 
and vice versa. Brackett's case 94 began with sudden onset as polyuria 
following mental shock, and just before death, seven months later, the 

93 See Blaikie's case, Lancet, 1904. 

94 Lancet, 1899, No. 25. 



THE UEINE 



205 



specific gravity rose from 1002 to 1006 to 1026 and much sugar 
appeared. One interesting thing which has attracted considerable 
attention is the fact that certain patients will void an amount of urine 
in excess of the water ingested. For instance, in one of Futcher's 
cases, very carefully studied both as regards the measuring of the fluids 
ingested and that of the urine, and in which the patient was carefully 
watched to avoid any errors, the urine exceeded the intake of fluids, 
even including the water content of the solid food, by an amount 
varying from 400 to 6355 cc. per day. And this continued for a long 
time. 

The urea may reach 80 gms. per day or more. This is due to the 
diet, such cases having an enormous appetite ; in other cases it is 
diminished. The sodium chloride and phosphoric acid output is nor- 
mal, sometimes slightly increased. 

Inosite is occasionally found. This occurs in normal persons with 
polyuria resulting in the drinking of large amounts of water, and 
hence has no importance, it probably being the inosite washed out 
from the muscles. The total carbohydrates are not increased (Edsall, 
Alfthan). 

Many believe that a condition of bradyuria exists, that is, that the 
fluid ingested causes an increased urine output more slowly and the 
increase lasts longer than normal. 95 

Glycuronic Acid, CHO(CHOH) 4 COOH. — Glycuronic acid is an 
intermediate product of glucose metabolism, and appears only when it 
is saved from further oxidation by union with some body with which 
it can be conjugated, as camphor, or substances arising in the body as 
indoxyl, skatoxyl, paracresol, phenol, et al., or certain nitrogenous 
combinations, as uramidoglycuronic acid. It occurs in amounts less 
than 25 mg. per 100 cc, but its amount varies with these other bodies, 
and hence its variations are accidental so far as it itself is concerned. 
The acid crystallizes with phenylhydrazine in beautiful needles whose 
melting point is 114 0 to 1 1 5 0 C, but free acid does not occur in the 
urine. It has the reducing properties of glucose for Cu, Bi, and Ag, 
reducing copper as well as glucose. It does not ferment. With HC1 
and phloroglucin or orcin it gives the same color tests as the pentoses 
and including the spectrum. It gives the furfurol test. While itself 
dextrorotary, it occurs always in paired compounds which are all of 
them lsevorotatory. These bodies explain the normal laevorotation of 
the urine of from 0.05 0 to 0.17 0 . It is much increased after the inges- 
tion of camphor which pairs with it, and also after chloral hydrate. 
The orcin reaction is the most convenient one to use (see page 188). 

Its chief clinical importance is the fact that its paired acid com- 
pounds occur normally, that they reduce copper after somewhat pro- 
85 Pribram, Deutsches Arch. f. klin. Med., 1903. 



206 



CLINICAL DIAGNOSIS 



longed boiling, and are kevorotatory. If, therefore, the sugar reaction 
is suggestive, the fermentation test negative, and the orcin test good, 
they may be suspected. Since this acid has been shown to be a 
product of the normal oxidation of glucose, it is increased in diabetes 
mellitus, some claiming that in very mild cases the unoxidized sugar 
is present only in this form. Edsall 96 showed that the excess of 
benzoyl esters in diabetes was not always due to an excess of glycu- 
ronic acid, but found an increase in the unfermentable carbohydrates. 
They are present in all intoxications. He suggested that their increase 
may be considered a protective measure of the body to combat these 
intoxications. Glycuronic acid is increased in a great variety of con- 
ditions. Edsall doubts that it can even be used to indicate a latent 
diabetes, while recently Fisher has given evidence that the pairing- 
of glycuronic acid occurs before any oxidation of the dextrose molecule 
has occurred, which would rather destroy the theories concerning its 
importance in diabetes. 

Alkaptonuria. — This very rare and interesting condition has of late 
attracted considerable interest. Its rarity is evident from the fact that 
but 40 cases (29 of them men) were reported up to 1902 (Garrod). 
Of these, only four were in America (Futcher), and the number has 
not much increased since attention was called to the abnormality. 

It seems a congenital and life-long condition, although some cases 
are intermittent, and Mittelbach's patient is confident that his followed 
an injury. 

Such cases occur without symptoms and are discovered accidentally, 
by the mother, for instance, finding the napkins of the infant darkly 
stained, or an insurance company refusing an applicant as a diabetic. 

Most observers consider alkaptonuria as a variant of metabolism; 
that the body is unable to burn homogentisinic acid ; and that it is com- 
parable to glycosuria. Tyrosine while the mother-substance of some 
cannot explain all of it. It is a normal intermediate product of the 
breaking down of the albumin of food and of the organs. 97 

Alkaptonuria seems to be a family disease, 19 of 32 cases occur- 
ring in seven families, one family having 4 cases, but there is only one 
case of inheritance (Osier's case). 98 Gar rod 99 finds that 60 per cent, 
of the cases are children of parents who are first cousins. Others think, 
that it is due to an intestinal mycosis, a peculiar intestinal ferment, etc. 

The amount of reducing substance excreted varies from about 3.2 
to 6.9 gms. in twenty-four hours. It is of interest (said Garrod) that 

96 Univ. of Penn. Med. Bull., April, 1906. 

97 See Langstein and Meyer, Deutsches Arch. f. klin. Med., 1903, vol. lxxviii. 
p. 161. 

9S Lancet, January 2, 1904; see Futcher, New York Med. Journ., January,. 
1898. 

99 Ibid., December 13, 1902. 



THE UEINE 



207 



the output is for different cases so constant, and that a person either 
excretes this amount or none. No traces, no gradual increase or de- 
crease, are seen. 

The amount excreted depends somewhat on the diet, since it is 
reduced to about one-half on hunger days, and is reduced a little 
by a vegetable diet. 

Its period of greatest excretion was supposed to be from one to 
three hours (Mittelbach) after a heavy meal, a point in favor of its 
intestinal origin rather than due to abnormal metabolism, since the 
greatest output of the products of metabolism is from four to eight 
hours after a meal. Garrod, 100 however, found the latter true here, 
hence its origin in the tissues. 

The urine when fresh is very acid, of normal color, but rapidly be- 
comes dark, reddish-brown and syrupy from oxidation, especially if 
made alkaline. It gives the copper tests, but not Nylander's ; AgNO s 
is reduced in the cold, it does not polarize, is not fermented, and gives 
no crystals with phenylhydrazin. 

Of the alkapton bodies, two at least have been isolated, homogen- 
tisinic and uroleucinic acids. V. Jaksch includes the glycosuric acid of 
Marshall, which, however, may for the most part be the first men- 
tioned. Other bodies may be present. Urines supposed to be rich in 
pyrocatechin are for the most part really cases of alkaptonuria. 

Homogentisinic acid, C 6 H 3 ( OH ) 2 CH 2 COOH, is the most im- 
portant and in most cases the only alkapton body. It is to this that 
the characteristic reactions of the urine are due. Its mother-sub- 
stance seems to be tyrosine, for this, if fed a patient, is excreted as 
this acid, especially if the tyrosine be given in small doses. 

To isolate, the urine is made strongly acid with H2SO4 (i to 12), 75 cc. per 1 
litre of urine. It is evaporated on a water-bath to one-tenth volume and shaken 
out four or five times with three volumes of ether. The ether is then distilled 
off, the residue dissolved in water (30 to 60 volumes), filtered, the solution heated 
to boiling and precipitated with 20 per cent. PbAc. This is quickly filtered while 
hot to separate the resinous brown precipitate. On standing the lead salts will 
slowly separate. These are decomposed by H2S, and the filtrate carefully evapo- 
rated first on the water-bath and then in vacuo. The acid will crystallize out. 

Garrod recommends that the urine be heated to boiling, and from 5 to 6 gms. 
of solid PbAc per 100 cc. of urine be added. When these are dissolved the urine 
is filtered, and the filtrate allowed to stand twenty-four hours in a cool place. 
The lead crystals are ground fine, suspended in water, decomposed with H 2 S> 
filtered, evaporated first on the water-bath and then in vacuo to a syrup. 

Uroleucinic acid, C 6 H 3 (OH) 2 C 2 H 3 OHCOOH (?) has also 
been found in alkaptonuria. It is very similar to the above, with the 
reactions practically the same. It may be separated from it since it 
is precipitated by basic lead acetate. Garrod found none in the 
urine of those in whom years previously others had found it. 

100 Lancet, November 30, 1901. 



208 CLINICAL DIAGNOSIS 

Baumann's quantitative method : 101 10 cc. of the urine are mixed in a flask 
with 10 cc. of 3 per cent, ammonia. To this mixture one adds at once several 
cubic centimetres of tenth-normal AgN0 3 , shakes it a little, and allows it to stand 
five minutes. To the mixture are then added 5 drops of 10 per cent. CaCl 2 and 
10 drops of ammonium carbonate solution. After shaking, it is filtered. The 
brown-colored but entirely clear nitrate is tested with silver nitrate. If there at 
once occurs a strong precipitation of reduced silver, in the second test a larger 
amount, even twice as much silver solution is added to the mixture of 10 cc. of 
urine and 10 cc. of ammonia. As soon as one has determined approximately the 
amount of the silver solution necessary for oxidation, the end reaction may be 
determined with HC1. it being near when the deep brown fluid on the addition of 
HC1 takes a light red color. The end reaction is reached when the filtrate from 
the silver precipitate on acidifying with dilute HC1 gives a slightly visible cloudi- 
ness of AgCl. One can determine this point very sharply after repeating the de- 
termination from four to six times. If more than 8 cc. of the silver solution are 
necessary, on repeating the determination 20 cc. rather than 10 cc. of ammonia 
are to be used. 

One gm. of the water-free homogentisinic acid is reduced with the above tech- 
nique by a quantity of silver solution which contains 2.6 to 2.65 gms. of silver ; that 
is, 240 to 254 cc. of the tenth-normal silver solution. Hence 1 cc. of the tenth- 
normal solution indicates 0.004124 gms. of the acid. 

The method is rather approximate, having an average error of 6.1 per cent. 

PROTEIDS IN THE URINE 

Albumin Tests. — For all albumin tests the urine must be as fresh 
as possible and perfectly clear. This latter may be obtained usually by 
nitration, and this is the best way, using many thicknesses of paper. 
If, however, the turbidity is due to bacteria, Kieselguhr is often used. 
Kieselguhr has its objections, since it quite certainly removes from the 
urine some of the albumin. MgO is recommended, and also the 
asbestos filter. 

It is always best to dilute a concentrated urine, since all albumin 
tests are rendered even more distinct. Although the albumin is diluted, 
this loss is more than offset by the gain from the dilution due to 
the elimination of the influence of disturbing bodies of concentrated 
urines. 

Hallauer's work 102 is interesting as showing the importance of this. If normal 
urine be concentrated by heat to one-half its volume and then serum albumin 
added, the heat and acetic acid test is even improved, but the heat and nitric acid 
test, Heller's, and the potassium ferrocyanide tests are negative. If the urine be 
previously evaporated to one-quarter its volume, none of these tests will show 
the albumin, yet all are positive if this concentrated albuminous urine be diluted 
to its original volume. The potassium ferrocyanide test is the first to disappear, 
which it does when the specific gravity is about 1030. Urea and the neutral salts, 
especially phosphates, are the disturbing bodies. 

The specimen should be carefully chosen. In a definite case of 
nephritis this is not necessary, but in very mild cases the albumin may 

101 Zeitschr. f. Physiol. Chem., 1892, vol. xvi. p. 270, or Hoppe-Seyler, Chem- 
ische Analyse, seventh edition, p. 460. 

102 Munch, med. Wochenschr., 1903, p. 1539. 



THE URINE: ALBUMINURIA 



209 



be present only during certain hours of the day. Such patients should 
send for examination the urine first voided in the morning and that 
voided at the end of a hard day's work. The morning urine is often 
albumin-free. 

Heat and Acetic Acid. — -The albumin is precipitated by heat as co- 
agulated albumin. This method is good unless only minimal traces 
be present. A test-tube is filled almost full of the clear neutral or 
faintly acid filtered urine and heated at the top to a boil, the tube 
being held by its lower end. In case only a very slight trace of albumin 
be present, it were much better to use an alcohol flame, since the 
slight deposit on the glass from the burning gas will simulate a very 
slight cloud of albumin. If a cloud is produced, it can be easily recog- 
nized by comparing' the upper with the lower half of the tube while 
holding the tube against a black background. A cloud may be due to 
albumin or to calcium phosphate and carbonate. A few drops of 5 
per cent, acetic acid are then added until the urine is distinctly acid. 
In case it is albumin, the cloud will rather increase and even become 
flocculent ; with very much present, the tube may be inverted without 
the loss of a drop. In case it is inorganic phosphates, it will disappear, 
the carbonates with effervescence. From 1 to 3 drops of 25 per cent, 
acetic acid per 10 cc. is recommended by Hammarsten. The urine 
should be boiled after the addition of each drop of the acid. 

If no cloud is produced, albumin may still be present, and acetic 
acid should be added even though the urine be perfectly fresh and 
remain clear on boiling. A cloud may appear, showing that the urine 
was not sufficiently acid for the precipitation. Here again the urine 
should be boiled after each drop. In some cases the fresh urine is too 
acid for the coagulation, in which case an alkali may be added, which 
will produce or at least increase the precipitation. If the test appear 
negative, the test-tube is allowed to stand for about fifteen minutes, 
time being allowed for the coagulum to appear. In case the urine is 
poor in salts, the test is much improved by adding one-tenth volume 
of saturated NaCl. An excessive acid must be avoided, since it gives 
soluble acid albumin. It is therefore possible to add too little or too 
much, and a mere trace is easily lost ; at least, the faint cloud may be 
either albumin or phosphates, which, one cannot say, since both will 
disappear or remain if too much or too little acid be used, and the 
proper amount to add is hard to determine. 

The more chronic the nephritis the whiter the albumin cloud. The 
more acute the browner the precipitate. 

The other coagula which may appear are : The so-called " nude 0 -albumin?' 
This is precipitated in the cold by acetic acid. Two tests, the one in the boiled, 
and the other the unheated urine to which acetic acid has been added, may be 
compared to see if this body will explain all the precipitate. The urine gives a 
14 



210 



CLINICAL DIAGNOSIS 



better test for nucleo-albumin when diluted; the precipitate is soluble in excess 
of acid. 

Resinous acids may cause error in case a great excess of acetic acid is added. 
This precipitate, which is soluble in alcohol, may be met with after the inges- 
tion of different resinous bodies, — turpentine, benzoin, copaiba, balsam of Peru, 
Tolu, cubebs, etc. 

Heat and Nitric Acid. — The urine is boiled as above, and then con- 
centrated HNO s added until strongly acid. The albumin precipitate 
is insoluble in fair excess, and hence the danger here is that too little 
rather than too much acid will be used. As a rule, about one-twentieth 
to one-tenth volumes are necessary. Hammarsten recommends one to 
two drops of 25 per cent, nitric acid per 1 cc. of urine. A flocculent 
precipitate indicates albumin. The phosphates are dissolved. The 
urine should be boiled before and after the addition of each drop of 
acid. If after adding the acid the urine be allowed to cool and a 
precipitate either appears or increases, it is of " albumose." The 
" nucleo-albumin " is soluble in this excess of NH0 3 . On cooling; uric 
acid may precipitate, but this should not confuse, since it is granular 
and colored. If only a trace of albumin be present, the addition, of 
nitric acid may cause no precipitate unless the urine be rich in salts ; 
on the other hand, a great excess of HN0 3 may dissolve the trace 
which does appear, hence the boiling should be repeated after each 
drop. Here again the coagulation of a trace may not occur at once, 
and the tube should be allowed to stand some time, and then the 
coagulum may be found at the bottom. 

By the above technique are excluded the " albumin normally present," the 
"nucleo-albumin," and "albumose" (Bence-Jones body). The urates may deceive 
in a concentrated urine, but this precipitate is never flocculent ; also the resinous 
acids. Biliverdin and other pigments are said to confuse, but their precipitate is 
soluble in alcohol. 

Another method much recommended is to render the urine strongly acid 
with a few drops of acetic acid. One-sixth volume of 30 per cent. NaCl (giving 
a 4 per cent, solution) is then added. A precipitate may appear in the cold, 
possibly of globulin, which is increased by heat. The urine is then heated as 
above. All albumins are precipitated, the " nucleo-albumin " cloud is slight or 
absent. Albumoses are shown which will dissolve on warming. The resinous acids 
may deceive. This test is less delicate than the preceding. 

The heat and acid tests are very delicate, indicating 0.005 gm. per 
loo cc. They should, however, always be confirmed, since the faintest 
trace is uncertain ; by using them we lose the albumoses. 

Heller s Nitric Acid Test. — This is a contact test between urine 
and nitric acid; if albumin be present there is formed a line of pre- 
cipitate at the place of contact. It has the advantage that no flame 
is used. The albumin is precipitated as an acid albumin, which is in- 
soluble in a fair excess of acid. Of all the mineral acids used, nitric 
acid requires less per molecule of albumin than the others. The pre- 



THE UEINE: ALBUMIN UEI A 



211 



cipitate is, however, soluble in a great excess of the acid. The test is 
very delicate, indicating, according to some, 0.007 P er cent, and to 
others even 0.002 per cent. (Hammarsten). For this cold contact test 
is used a very large test-tube, or a wine-glass, or the albumoscope 
which is much to be recommended (a U-shaped tube with one arm 
very slender, allowing a beautiful layering of the two fluids [see Fig. 
29], called also an horismascope). 

Into the test-tube is poured about two inches of urine, and then one- 
third its volume of concentrated nitric acid is allowed to flow under 
very slowly, the tube being much inclined; or, the urine is made 
to flow on top of the nitric acid. Still better, the fluid added last is 
introduced from a pipette. The nitric acid must be colorless, *con- 




FlG. 29.— Horismascope. A, The arm of the U-shaped tube with fine bore ; B, bulb in which HNOj, 
is poured after the tubes are filled with urine ; C, wide-bore arm for urine, with background. 

taining no nitrous acid since its effervescence with urea at the line of 
contact will disturb the ring and a faint one be lost ; the same is true 
if much carbonate be present, as in an old urine. The line should be 
searched for against a dark background. In case the ring does not at 
once appear, one should wait, as it may show later. If no ring appears 
until three minutes the albumin is less than 0.003 P er cent - This ring 
of acid albumin will appear exactly at the surface of contact ; its thin- 
ness depends on the amount of albumin and also on the skill with 
which the urine has been superimposed. 



The colored ring which always appears in concentrated urines should not 
deceive. This may be red or reddish-violet in color, but contains no precipitate. 



212 



CLINICAL DIAGNOSIS 



The urate ring is present in all concentrated urines, and sometimes deceives. 
It is, however, above the line of separation, and when the test is well made is 
separated from it by a layer of clear urine from ^ to i cm. broad. This ring 
is broader than the albumin ring, less distinct, disappears on warming, and does 
not appear if the urine be diluted. To dilute the urine to about one-third volume 
does not interfere with the delicacy of the test nearly as much as is gained by the 
elimination of this ring. 

One interesting case, the urine of which was sent to the clinical laboratory 
to demonstrate this fact, shows the value of diluting the urine. A consultant 
was called to see a case in which the attending physician had made a diagnosis 
of " albumosuria," the presence of Bence-Jones body in the urine, and had given 
a hopeless prognosis. It seems that he had tried this albumin test, obtained an 
abundant precipitate of urates which entirely clouded the urine and which disap- 
peared on warming. 

" Nucleo-albumin." — This is present as an opalescent ring 0.5 to 1 cm. above 
the line of contact, sometimes extending down to it, and which disappears on slightly 
shaking the tube that the acid may be mixed with the urine, as this body is 
soluble in nitric acid. In the undiluted urine this ring appears somewhat later, 
is faint, does not resemble much the albumin ring, and in the case of a diluted urine 
appears even more rapidly and is clearer than in the concentrated. 

Resinous Acids. — These may form a whitish ring above the line of contact 
and partly clear on warming. These bodies are soluble in ether, which should 
be added in great excess to prevent an emulsion. The precipitate is pipetted off 
for this examination. If suspected, the following test should be used. To from 
8 to 10 cc. of urine are added 2 to 3 drops of HC1 in the cold, which will pre- 
cipitate these acids. On adding more HC1 and heating a red color results. These 
resinous acids may also be extracted with ether from the urine made strongly 
acid with acetic acid. 

The " albumoses " (Bence-Jones body) will also give a very heavy ring at 
the line of contact, which disappears on warming. 

The bile acids will also give a precipitate in concentrated urines. 

Urea nitrate may crystallize out. This line, however, which may form a solid 
crust between the two fluids, is so solid and so definitely crystalline that it will 
never deceive. 

Hammarsten recommends that as a matter of routine all urines be diluted to 
a specific gravity of 1005. Dilution excludes all the above disturbing bodies 
except albumose and nucleo-albumin. 

This test should never be trusted alone, but confirmed by another. Many 
workers recommend that it be used first. 

Potassium Ferrocyanide and Acetic Acid. — A few drops of acetic 
acid are added until the urine is quite acid (containing about 2 per 
cent, of acetic), K 4 FeCN 6 (5 per cent.) is then added drop by drop, 
avoiding an excess. When the proper amount is added albumin is 
indicated by a cloud or flaky precipitate. If the observer be expert, 
this test is more accurate than Heller's. It takes, however, some expe- 
rience, so much depends on the amount of reagents and the amount 
of salts present. The test is particularly valuable in quantitative work 
when it is desired to know if a solution has been rendered albumin- 
free. 

The albumoses are also precipitated. " Nucleo-albumin " is precipitated, but 
also by acetic acid alone. 

A hot urine must not be tested, nor any reagent used containing iron as 
Kieselguhr, 103 else clouds of inorganic precipitates are produced. 

103 Bardack, Zeitschr. f. inn. Med., 1902, No. 42. 



THE UBINE: ALBUMINURIA 



213 



Tanrcfs Test. — This reagent is made by dissolving 1.35 gms. 
HgCl 2 in as little water as possible with 3.32 gms. KI (hence one 
molecule HgCl 2 equals four molecules KI). To this solution are 
added 50 cc. of water and then 20 cc. of glacial acetic acid. This 
solution is added drop by drop to the urine, which will cloud should 
albumin be present, until the cloud just begins. It is exceedingly deli- 
cate. It indicates also " nucleo-albumin," " peptone," soluble on warm- 
ing, alkaloids, and the albumoses. In French clinics we have seen 
this test used with the most satisfactory results. 

Spicglcrs Test. — Spiegler's test consisted originally of HgCl 2 , 8 
gms. ; tartaric acid, 4 gms. ; glycerin, 20 gms. ; water, 200 cc. It has 
recently been modified by Jolles : HgCl 2 , 10 gms.; succinic acid, 20 
gms. ; NaCl, 10 gms. ; water, 500 cc. 

This is the most delicate test of all. The urine is first filtered, ren- 
dered acid by a few drops of acetic acid to hold the carbonates in 
solution and to precipitate the nucleo-albumin, which is filtered off if 
present, since this also is precipitated, and then superimposed on the 
above reagent. A very sharp ring is produced by albumin. By means of 
it Spiegler claimed 1 : 50,000 could be detected, but as modified it is 
said there can be detected 1 : 150,000 to 350,000, the latter in the case 
of Jolles's modification. The advantage claimed for it is that it is 
definitely positive or negative, not suggestive. This detects also albu- 
moses, but not deutero-albumose. In case the urine be very dilute, that 
is, specific gravity 1005, the original test is of little value, hence NaCl is 
an ingredient of the modified solution. That the reagent will not mix 
with the urine, its specific gravity should be about 1060, hence a heavy 
acid is used and glycerin or saccharose added, and still more if neces- 
sary, as in a case of diabetes. 

Various other tests have been proposed : Metaphosphoric acid in solid form, 
a piece the size of a pea being added to a test-tube of urine ; picric acid is used 
also in the same way. Oliver has recommended papers saturated in the reagents 
because of the ease in carrying them around. Against all such tests should be 
said, however, that they are far inferior in delicacy to the above-mentioned tests, 
and hence fail where most needed. 

There is a long list of very delicate tests recommended. In general it may 
be said that there is danger in these delicate tests, since it is granted a trace of 
albumin is normally present, and the test used should be only delicate enough 
to indicate a pathological amount. Almost any two tests which control the one 
or the other are good enough, providing the worker understand the shortcomings 
of each and be experienced in their use. 

The order of delicacy of these tests is : Spiegler's, Tanret's, then 
heat and acid ; next K 4 Fe,CN 6 ; next Heller's, then picric acid, and 
various others. This order, given by Huppert, is not accepted by 
some, who claim that they can with Heller's test properly performed 
in a wine-glass get more delicate results than with the heat. Senator 
recommends Heller's test, since it shows albumose. He advised 



214 



CLINICAL DIAGNOSIS 



against heat as the test of preference, since traces are so often lost and 
albumose may not even be suspected. In general, it should be said 
that no one test is certain, but each should always be confirmed by at 
least one other. The heat and acid and the Heller's are a good 
combination. 

Quantitative Determination of Albumin. Scherer's Method. 
— About 500 cc. of faintly acid urine are filtered. About 5 cc. are 
then poured into a test-tube and this boiled and then filtered until the 
filtrate be clear. The presence of albumin in the filtrate is tested in 
the cold with acetic acid and potassium ferrocyanide. If the filtrate 
be albumin-free the urine is ready for immediate use. In case, how- 
ever, that a slight trace is still present, two or three drops of 50 per 
cent, acetic acid are added to the whole amount, well stirred, and a 
second trial test made. This is to be continued until the filtrate of 
these sample portions is albumin-free. When near the border-line in 
some cases one drop of acid too much will spoil the whole and sodium 
hydroxide solution must be added drop by drop. The work is much 
facilitated by adding 0.1 volume of saturated NaCl ( Cohnheim ) , this 
increase in the sodium chloride rendering the precipitation more com- 
plete. In this case a clear filtrate is also albumin-free. The addition 
of this salt is to be recommended as a routine work, and we have saved 
a great many weary hours by so doing. Of course, a proper correction 
for change of volume is necessary. The urine now of the right acidity 
is measured and boiled before the bacteria change this at all. Two 
portions are then coagulated ; first on the water-bath, then over the 
free flame until the precipitate is flocculent and the supernatant fluid 
is clear. 

The amount of urine used will depend' on the amount of albumin 
present. A general rule is that the weight of dried albumin on a 
paper shall not exceed 0.3 gm. Larger amounts than this it is ex- 
ceedingly difficult, we think impossible, to dry to constant weight. In 
case the urine is very rich in albumin, it is better that a small, accu- 
rately measured amount be added drop by drop to a beaker of boiling 
water or, better, salt solution. 

The urine is then filtered through a dried and weighed filter paper, 
the precipitate washed chlorine-free with hot water, then with alcohol 
and ether, and then dried to constant weight at no 0 C. To obtain 
constant weight may seem a simple matter, but it is far different, since 
even at lower temperatures than this constant heating will produce a 
certain loss in weight. Weighing-glasses with ground-glass stoppers 
are recommended, and drying ovens in which the heat can be well con- 
trolled. The bulb of the thermometer should be on a level with the 
glasses, which rest on an asbestos sheet. After the weight has become 
almost constant they should be weighed at stated intervals, preferably 



THE URDsE: ALBUMINURIA 



215 



about an hour apart, until the weight is quite constant. Control tests 
should always be used, and even with the best work the error is often 
as high as I per cent. 

Salkowski 104 recommends the following when very much albumin 
is present. A small accurately measured amount of urine is mixed 
with i o to 20 volumes of 95 per cent, alcohol and brought to a boil on 
the water-bath. It is then cooled, decanted, washed with hot water, 
filtered, washed, then placed in a weighed platinum 
crucible, and dried to constant weight at 1 1 5 0 C. The 
weight of the ash is then subtracted. 

Esbach's Tubes. — In these tubes (see Fig. 30) are 
mixed a definite quantity of urine and a reagent made 
up of picric acid, 10 gms., citric acid, 20 gms., water, 
to make 1 litre. Marks on the tubes will indicate the 
amount of each to be used. The tube is then well 
corked, and is reversed slowly a dozen times, that the 
fluids may be well mixed. The tube is then allowed 
to stand quiet for just twenty-four hours, at the end 
of which time the height of the column of precipitate is 
read on the graduated scale of the tube. The reading 
is given in grammes of albumin per litre. 



It will be seen that this is only a refined method of an older 
test, in which case the boiled urine was allowed to settle and the 
height of the precipitate roughly estimated, " 50 per cent, of 
albumin" meaning that the tube was about half full of precipitate. 
This method has the same objections as the older, and we fear 
has greater appearance of accuracy than it really possesses. 105 

That the test may be as satisfactory as possible the following 
points must be observed : The urine must be rendered acid by 
acetic acid. The tube should not be shaken too vigorously. It 
should stand in a room of almost constant temperature, since a 
change in this may easily make a difference of 100 per cent., the 
precipitate sinking much more rapidly in a warm room. In case 
a faint cloud appears which does not settle, it is probably 
" nucleo-albumin," still, traces of albumin will not settle. The 
test is much more reliable in case the urine be so diluted that 
the precipitate will rise to a point between the one and the four 
mark. Sometimes the albumin will collect at the top of the tube, 
not, however if the urine has been diluted. This test, although 
very unsatisfactory, is still a favorite of the practitioner. It has 
its strong points, and gives much information. The two points that should be 
remembered, however, are, that the temperature must be fairly constant, and that 
it is not as accurate as it looks ; a difference in reading of one or even three 
grammes per litre in a marked case may not indicate a difference in the urine. 



■R 



U 



Fig. 30. — Esbach's 
albuminometer. 



Not nearly enough attention is paid to an approximate estimate 
from the size of the ring in contact tests, such as Heller's test, made 

104 Berl. klin. Wochenschr., March 3, 1902. 

105 Johns Hopkins Hosp. Bull., January, 1903. 



216 



CLINICAL DIAGNOSIS 



in a " Collamore wine-glass " half filled with urine, then underlaid 
with approximately one-third its volume of nitric acid. By " slightest 
possible trace " is meant the smallest amount which can be detected 
as a haze under most favorable conditions (black background, etc.) ; 
" very slight trace " means slightly more; a " slight trace " can be seen 
without a black background and also from above, although the bottom 
of the glass is distinctly seen; a " large trace " (about o.i per cent.) is 
a clearly seen ring but not flocculent, quite dense but not opaque 
when seen from above; through the ring made by J /$ per cent, the 
bottom of the glass cannot be seen, but a faint ray of light is trans- 
mitted; 0.25 per cent, gives a zone quite flocculent from the side and 
opaque from above; 0.5 per cent, and above, the ring is very dense 
and flocculent. Above this one cannot go by this method. The width 
of the ring is not so important (condensed from Ogden, " Clinical 
Examination of the Urine "). 

Rossler used Jolles's test in a similar way, but depended more on 
the thickness of the ring. 106 

Centrifuge Method. — Purdy has recommended that in graduated 
centrifuge tubes be mixed 10 cc. of filtered urine, 3.5 cc. of 10 per 
cent. K 4 FeCN 6 , and 1.5 cc. of acetic acid. The urine is then cen- 
trifugalized at a uniform speed of 1 500 revolutions per minute in a 
centrifuge the arm of which is of such length that the distance from 
the centre of rotation to the tip of the tube is 7 inches. It is centrifu- 
galized three times, five minutes each time; 1 / 10 precipitate indicates 
Veo P er cent - by weight of albumin. In his recent edition he gives a 
table with the equivalents of the readings. This test, satisfactory as.it 
may seem, has not given very good results in our hands, although better 
than the Esbach tube. It is an interesting fact that two of the makers 
of the Purdy centrifuge were unable to supply us with an arm which 
conformed to his specifications as regards length, hence one must be 
made to order. It is difficult also to obtain graduated tubes with the 
sharp point as he represents them. We have found it no easy matter 
to keep a centrifuge running uniformly at this rate unless one stands 
over it and watches the taxometer during the entire time. The exact 
time the urine is centrifugalized is of great importance. 

Roberts and Stolnikow's Method. — This method is based on the observation 
that with Heller's test a ring appearing from two and one-half to three minutes 
after the test is made indicates an albuminuria of 0.003 P er cent. Diluted urines 
are therefore tested until a dilution is obtained in which the ring appears in this 
time. The test should be performed very carefully. The sides of the tube should 
not be wet with the nitric acid, and the urine should be added slowly from a 
pipette. 

This determines at the same time the " nucleo-albumin " and resinous acids. 
106 Deutsches med. Wochenschr., 1903, No. 19, p. 335. 



THE URINE: ALBUMINURIA 



217 



In the Lohnstein method the specific gravity of the urine is determined before 
and after the albumin is removed by heat and filtration. The difference multiplied 
by an experimental coefficient gives the albumin per cent. 

It is often necessary to remove albumin from the urine before con- 
tinuing- with other quantitative work. To do this Hofmeister's method 
is the best. To the urine an excess (10 cc.) of sodium acetate, 40 per 
cent., and concentrated Fe 2 Cl 6 are added, until the whole is of a red 
color. The urine is then neutralized or very faintly acidified and 
then boiled. The precipitate o<f basic ferric acetate will carry down 
with it all of the albumin and leave the solution albumin- and iron- 
free, and this filters beautifully. This method cannot be used if glu- 
cose be present, since some ferric oxide remains in solution. 

For practical purposes it is sufficient to boil and to add acetic acid 
until the precipitate is flocculent and the filtrate clear. The filtrate 
may be further tested as in the quantitative work. The urine should 
then be restored to the original volume. 

Proteids Present. — By albuminuria is- meant the presence in the 
urine of a coagulable albumin which has. escaped through the cortex 
of the kidney (for false albuminuria, see page 224). Nearly always 
there are present serum albumin, " serum globulin," and the so-called 
u nucleo-albumin." 

The albumin quotient is the amount of serum albumin divided 
by the amount of " serum globulin " present (Hoffmann). This quo- 
tient varies considerably in various cases, and in the same cases during 
various stages. In some cases serum albumin alone has been found. 
This was true of one case of cancer of the stomach, and of certain 
cases of nephritis during, however, limited periods. Globulin alone 
has been found in one case of acute nephritis, in the case of one woman 
during the puerperium, and in one case of leukaemia. (For " nucleo- 
albumin," see page 219.) 

Serum albumin is present normally even as much as from 22 to 78 
mg. per 1 litre (Morner). It is soluble in water, coagulated by heat 
in acid solution at a temperature varying from 56 0 to 81 0 C, depending 
on the amount of salts present, especially the phosphates, also the urea, 
and lastly on its own concentration; it is coagulated by absolute 
alcohol, which coagulum is soluble in water unless it has been in contact 
with the alcohol for a long time. This is rendered even more insoluble 
by weaker than by stronger alcohol. The solubility of this coagulum 
should be borne in mind by all doing quantitative work with this pre- 
cipitate. Serum albumin is laevorotatory, [a] d = — 62. 6°. The 
albumin plus alkali gives a soluble body which, when united with a 
base, forms an albuminate much less soluble in water than is albumin, 
and which will therefore give a spontaneous precipitate of albumin in 
a concentrated urine. 



21S 



CLINICAL DIAGNOSIS 



With mineral acids the acid albumin is quite insoluble until a 
large excess is added; in the case of acetic, however, a very slight 
over-acidity will dissolve the precipitate. 

Serum globulin is a term including several different bodies, 
among them pseudoglobulin, euglobulin, and fibrinoglobulin of the 
Hofmeister school, the reactions of which are rather different, but all 
of which exist in the blood-plasma. Euglobulin and fibrinoglobulin 
(fibrinogen) are probably always present normally in the urine. 
They are increased in the mildest forms of albuminuria (the so-called 
physiological and cyclic cases). In the severer cases albumin is pres- 
ent as well. 107 

The limits of precipitation by a saturated (NH 4 ) 2 S0 4 solution are 
the following, expressed in number of cubic centimetres of the satu- 
rated ammonium sulphate solution necessary to add to the urine, the 
amount of mixture to be in all cases 10 cc. Pseudoglobulin, 3.4 to 
4.6; euglobulin, 2.8 to 3.3; fibrinoglobulin, 2.2 to 2.9. 

Pseudoglobulin is not precipitated by acetic acid alone. Euglobu- 
lin occurs in almost all exudates and transudates, and in many urines, 
perhaps all. It is precipitated by acetic acid sometimes in the undi- 
luted urine, but usually one must dilute two or three times. The acetic 
acid must be carefully added, since the precipitate is partly or wholly 
soluble in excess. 

Serum globulin (the group) is present in amounts varying from 
8 to 60 per cent, of the total proteid ; very rarely only a trace is pres- 
ent. In the blood the ratio to albumin is as 1 : 1.5. Its great increase 
over the albumin cannot in all cases be explained by its greater diffu- 
sibility, since euglobulin, which is constantly present, is less diffusible. 
The quotient (see page 217) varies in nephritis, the globulin being 
the variable factor. Oswald considers that an output of euglobulin 
is the mildest form of albuminuria, and that this is precipitated by 
acetic acid in the cold. This body is present in largest amounts in 
parenchymatous lesions. (See also Calvo et al.) As the nephritis im- 
proves the relative amount of globulin diminishes, and increases with 
each acute exacerbation. In cases of contracted kidney and in chronic 
passive congestion with nephritis the quotient is the higher, from 2.8 
to 5.3, but in amyloid disease the quotient may be lower than 1. In 
acute nephritis it may be very low. It is low but not so markedly so 
in the albuminuria of pneumonia, but the reverse is true of typhoid 
fever. 

The globulins are insoluble in water, and in the urine are held in 
solution by the salts. If, therefore, to a beaker of distilled water a 
drop or so of urine be added a distinct cloud is seen. They are also 



Oswald, Munch, med. Wochenschr., 1904, No. 15. 



THE UKLNE: ALBUMINURIA 



219 



detected by diluting the urine till the specific gravity be about 1002, 
then adding one drop of acetic acid. 

Test. — The phosphates are precipitated by rendering the urine 
alkaline with ammonia, and are then filtered off. An equal volume of 
cool saturated ammonium sulphate is then added to the filtrate, which 
will perfectly precipitate globulin in neutral solution, the mixture 
allowed to stand one hour, and filtered. The precipitate is washed 
with half-saturated ammonium sulphate until the filtrate is albumin- 
free. Albumose and " nucleo-albumin" are also precipitated. The 
precipitate of ammonium urate is to be avoided, but this comes later 
and does not look the same. Serum albumin is not precipitated until 
total saturation. The precipitate is dissolved in a little water, heated 
on a water-bath, which coagulates the globulin and fibrinogen and 
albumose. It is then filtered, the precipitate washed with water and 
digested on a water-bath with 1 per cent. soda. It is then filtered and 
neutralized carefully with acetic acid. The precipitate is of globulin 
and fibrinogen. Albumose would not be precipitated. 

To determine globulin quantitatively the filtered urine is 
rendered neutral with ammonia, and to it is then added an equal vol- 
ume of saturated ammonium sulphate solution. The mixture, well 
stirred, is allowed to stand for some hours. It is then filtered through 
a dried and weighed filter, and the precipitate washed with half-sat- 
urated ammonium sulphate until chlorine-free. This filtration is a 
slow process. The funnel and all are then placed in the thermostat 
and dried for half an hour at no° C. The ammonium sulphate is 
then washed out with hot water, the precipitate dried with alcohol, 
ether, and then at no° C. to constant weight. In this case also the 
amount of urine used should be such that the weight of precipitate 
could not exceed 0.3 gm. 

Euglobulin, Nucleo- Albumin, Mucin, Morner's Body. — In the urine ill 
a great variety of cases occurs a proteid precipitated in the cold by 
acetic acid, giving an opalescence or true precipitate especially if a 
diluted urine be tested. It is difficultly soluble in an excess of acetic 
acid; the resinous acids should be excluded by the HQ test. With 
Heller's test the ring is not at the line of separation, but from 0.5 to 
1 cm. above it. Both rings, that of albumin and this, may be present, 
in fact the best " nucleo-albumin" rings are seen in nephritis. It may, 
however, extend down to the acid. The urate ring should be excluded 
by testing a diluted urine, which makes the " nucleo-albumin" ring 
even more distinct. It coagulates at about 56 0 C, and we have known 
the diagnosis of albumosuria to be made from this point. The test is 
always improved if a diluted urine be used, and, in fact, can be 
obtained in probably every normal urine if the salts be removed by 
dialysis. It is first seen near the acid, then, as this diffuses upward, 



220 



CLINICAL DIAGNOSIS 



the ring travels upward until all this proteid in the urine has been pre- 
cipitated and then dissolved. 

It is this body which first led to the belief that proteids were nor- 
mal constituents of the urine. Two other and contrary views were 
held, one that it was mucus, the other that it was nucleo-albumin, 
hence the condition was not a true albuminuria ; now many believe 
that it is globulin or a compound of serum albumin, hence is a true 
abuminuria. A precipitate on the addition of acetic acid occurs in 
the urine in a great number of conditions, so many that it is hard to 
classify them, and each writer has done so on the basis of his idea 
of its nature. Excluding the vesical cases, in which it probably is 
mucus, it is increased in the new-born ; in adults after severe exercise, 
nephritis, and various acute diseases, especially those affecting the kid- 
neys; fevers, especially pneumonia and typhoid (erysipelas, pleurisy, 
relapsing fever, meningitis). Its increase in leukaemia, reported first 
by Fr. Miiller, is of interest in connection with the idea that it arose 
from the nuclei of the leucocytes. 

Obermayer found it in 32 cases of jaundice, the amount depend- 
ing on the intensity of jaundice and ceasing with it. He found it 
present in scarlet fever in small amounts, diphtheria in the greatest 
amounts of all, in connection with albuminuria after poisons affecting 
the kidneys (pyrogallic acid, corrosive sublimate, etc.), in acute yel- 
low atrophy, and after compression of the thorax. 

In true nephritis it may precede the true albuminuria and also 
succeed it, and remain when, by severe dieting, etc., this intermits. 
Madsen considers it a good test of the earliest irritation of the 
kidneys. Euglobulin and fibrinogen are said to be the chief proteids 
in amyloid kidney. 

In orthostatic albuminuria this may be the only proteid present, or 
with albumin and pseudoglobulin. In febrile albuminuria it may ex- 
ceed in amount the serum albumin. It is present in but traces in chronic 
interstitial nephritis. When the blood-supply of the kidney of animals 
is cut off, this body in abundance is excreted, sometimes with albumin, 
sometimes not, and the same is true in partial suffocation. 

Pure mucus is present in the normal urine in traces (4.5 gms. in 
260 litres). This may be found in two portions, — an insoluble which 
gives the nubecula, and a soluble portion precipitated by acetic acid, 
which is only a very small fraction of the whole. Mucus would be 
expected since the urinary passages are lined with mucous membrane, 
and hence the urine will gather a little of its secretion as it passes 
down to the bladder. This mucin is much increased in catarrhal con- 
ditions of the urinary tract, and is added to the urine as a gelatinous 
precipitate as this passes over the mucosa. It is soluble in ammonia, 
precipitated by acetic acid, and soluble in excess ; from it a reducing 



THE UBINE: ALBUMINUBIA 



221 



body may be split off. It does not contain nuclein, nor chondroitin, 
hence it is a mucin, but the absence of the slimy character of the pre- 
cipitate with acetic acid gives it the term kt mucoid." It resembles 
ovomucoid of the hen's egg (Morner). In a recent case of prostatitis 
we found that the acetic acid precipitate was 0.066 gm. per 100 cc. of 
urine. The urine is precipitated carefully with acetic acid, and repeat- 
edly filtered through a weighed filter till the filtrate is clear. The 
precipitate is then washed with cold water acidulated with acetic acid, 
dried, and weighed. Another method giving slightly lower results is 
the following: A small amount (0.5 gm.) of Kieselguhr is dried at 
no° C. to constant weight, mixed with the urine, and dried with the 
paper and precipitate. It was much more rapid than the preceding. 
There are, however, other interesting and rare cases of true muci- 
nuria analogous to mucous colitis and fibrinous bronchitis with casts 
1 to 10 cm. long and 3 to 4 mm. thick in the urine. Such was v. 
Jaksch's case of " ureteritis membranacea" in which a spiral cast 
of the ureter of mucus and fibrin was voided ; in Frank's case it was 
a cast of the pelvis and upper ureter. He named the condition 
" pyelitis productiva." Four cases are on record. In the above 
cases the symptoms of the expulsion of the casts resembled those 
of renal colic. 

From the study of many cases of jaundice Obermayer decided that 
the body was nucleo-albumin, and hence all precipitates with acetic 
acid were considered nucleoproteid. 

Nucleo-albumin also may occur, but it is not the body that 
usually goes under that name, and it never occurs normally. Its pres- 
ence has been claimed as due to the breaking down of the cells of the 
urinary tubules. The kidney is an organ very rich in cells and the 
disintegration of these would certainly set free a certain amount 
of nucleo-albumin. This may explain the nucleo-albuminuria of acute 
nephritis, the condition in which this proteid is present most constantly 
and in greatest amounts, also the nucleo-albuminuria following the 
ingestions of poisons which affect the kidneys, and that clue to dis- 
turbances of renal circulation. Its origin in cases of jaundice is the 
bile. Nucleo-albumin is said by some to> be present in the blood, and 
it is possible that a certain amount reaches the urine from this source. 
It may come from catarrhal conditions of the urinary tract with 
desquamation of the superficial cells of the mucosa. Such is true in 
cystitis or pyelitis. In the case of women the genital tract is to be 
excluded as a source. 

It will be seen from the above list that the occurrence of nucleo- 
albumin is claimed for all cases in which theoretically nucleoproteid 
could occur; but in some of these conditions a true albuminuria 
occurs, and in others in which nucleo-albumin should be present in large 



222 



CLINICAL DIAGNOSIS 



amounts (urines containing abundant pus and epithelial cells) it is 
hard to get any precipitate at all on adding acetic acid. 

It is very clear, to one reading reports of cases, that in very few has 
the crucial test been applied, the proof that it is a phosphorus-containing 
body which acetic acid precipitated, and positive results would have 
to be scrutinized carefully, since it would be very easy for phosphorus 
to be an admixture from the urine. 

Again, the " salting out" points with ammonium sulphate do not 
quite agree with those of true nucleo-albumin from breaking down 
tissue. Matsumoto gives as limits of its precipitation, minimal o. i to 
0.8, maximal 1.6 to 2. 2. 108 

To prove the body nucleo-albumin it should be insoluble in acetic 
acid, precipitated by MgS0 4 , when boiled with dilute mineral acids 
give off no reducing substance, and on peptic digestion should give 
nuclein and contain phosphorus, but the last two tests it is almost im- 
possible to apply to the urine. 

Morner's Body. — Work which seemed very convincing and 
- which is now often quoted is that of Morner. 109 According to him 
most pf the so-called nucleo-albumin is a compound of true serum albu- 
min' : Within albumin-precipitating body which is formed on the addi- 
tion of acetic acid. Mprner/by dialyzing large amounts of urine and 
adding 1 to 2 parts per thousand of acetic acid, and then shaking 
with chloroform, obtained a. precipitate which much resembled nucleo- 
albumin. This occurs on an average of 41 mg. (22 to 78) per litre 
of urine. Further investigation showed this to" be a precipitate of 
serum albumin with chondroitin-snlphuric acid, which was always 
present and the most important, nucleinic acid, which is sometimes 
present in traces, and taurocholic acid, which is also sometimes present 
in traces, but which in the case of jaundiced urine may exceed the 
others in amount. Since there are these three possible combinations 
the precipitates will differ. If after removing this precipitate a little 
albumin be added to the urine, a second precipitate results of about 
54 mg. per litre, showing that these albumin-precipitating bodies are 
in excess. Since normally in* excess, any increase of precipitate would 
mean an increased excretion of albumin. The greater the predomi- 
nance of these precipitating bodies, however, the more does the pre- 
cipitate resemble nucleo-albumin. This union probably occurs after 
the addition of acetic acid. According to the relation between them 
the precipitate will resemble nucleo-albumin or serum albumin. If 
the albumin predominates, it may give its own proper tests. These 
bodies, and their relation, will explain the old statements, based on the 
common experience, that " a true albuminuria is sometimes preceded 

10s Matsumoto, Deutsches Arch. f. klin. Med., 1903, vol. lxxv. p. 398. 
109 Skand., Arch. f. Phys., vol. vi. p. 332, 1895. 



THE URINE: ALBUMINURIA 



223 



by the excretion of a body precipitated by acetic acid," that " the ex- 
cretion of mucus may precede or succeed an albuminuria," the belief in 
a " physiological albuminuria," also the opposing belief of recent years 
that this so-called physiological albuminuria was merely a nucleo-albu- 
minuria. 

Morner used the following method of isolation: 

The salts are dialyzed out of a large volume of urine and then acetic acid 
added, 2 cc. per litre. The precipitate is then dissolved in a little water and 
again precipitated with acetic acid. It may then be tested for the presence of 
chondroitin-sulphuric acid by heating on the water-bath with 5 per cent. HC1 
for a long time. If both sulphuric acid and a reducing body are present, this 
body is probably present. If the reducing body is demonstrated, but no sulphuric 
acid, it is probably mucus. If there is no sulphuric acid and no reducing body, 
and the precipitate then be digested with pepsin and organic phosphorus be found, 
the nuclein bases may be demonstrated in the products of digestion. Large 
amounts of urine, however, must be used for its detection. 

This explanation of Morner, satistactory as it would seem, and 
evidently based on very careful work, has received little confirmation. 
Stahelin 110 in one case of jaundice failed to find any of the " albumin- 
precipitating bodies," and thought the precipitate resembled the glob- 
ulins, a view held by Fr. Miiller in 1885; also in the acetic acid pre- 
cipitate of the urine of a case of pneumonia with a very heavy precipi- 
tate on adding this acid, no phosphorus could be detected. Matsumoto 
found it chiefly fibrinogen and euglobulin (see page 218). Oswald 111 
studied carefully this precipitate with acetic acid in the urines of cyclic 
albuminurics and nephritics, and decided it to be euglobulin and a 
trace of fibrinogen. These occur in the blood, but cannot be demon- 
strated there by the addition of acetic acid, since the salt content is 
too low. 

It is to be noted that in most of the above work small amounts of urine were 
used, not the large amounts of Morner ; again, that many will not agree that the 
limits of precipitation with saturated ammonium sulphate are alone sufficient 
for the recognition of a proteid. In conclusion, it may be stated that, however 
the present conflict between Morner and the Hofmeister school may be settled, 
both agree that there is a constant normal physiological albuminuria. 112 

J The Nucleohiston of Lilienfeld is a body arising from the break- 
ing down of leucocytes. It is precipitated by acetic acid and has a 
high phosphorus content. This is found in the urine especially of 
leuksemic patients, although its appearance is not alone due to the 
breaking down of these cells. 

Albumin, if present, is first removed ; the proteids of the urine are then pre- 
cipitated with alcohol, the precipitate washed in hot alcohol, then dissolved in, 

110 Munch, med. Wochenschr., 1902, p. 1413. 

111 Zeitschr. f. d. gesamt. Biochem., Bd. v, 1904. 

112 See, also, Calvo, Zeitschr. f. klin. Med., 1904, vol. li. 



224 



CLINICAL DIAGNOSIS 



boiling water, cooled, acidified with HC1, let stand, and the uric acid precipitate 
filtered off. To the filtrate is then added ammonia, the precipitate collected on 
a small filter, washed with ammonia till the wash-water gives no biuret reaction. 
The precipitate is then dissolved in acetic acid and tested for histon. This gives 
the biuret reaction, is coagulated by heat, and this coagulum is soluble in mineral 
acids. 113 

Fibrinuria. — Fibrinogen, fibrinoglobulin, occurs rarely in any 
amounts in the urine. The reactions are those of globulin, since this 
body belongs in that group. To recognize its presence, however, is 
easy, since there is a spontaneous coagulation on standing. 

Excluding those cases in which there is blood in the urine, fibrinu- 
ria is rare. It occurs in chyluria and in some rare cases of nephritis. 
In some cases the urine clots at once after voiding, the clot being some- 
times firm and in other cases gelatinous. Or this may occur before 
voiding, the clots being casts of the pelvis of the kidney or from the 
bladder (the term fibrinuria, of course, is strictly applicable only to 
these latter cases). In severe inflammation of the urinary passages, 
the bladder, ureter, or pelvis of the kidney, these clots may be formed. 
The reason for this is not known, since most of the inflammatory exu- 
dates do not coagulate. We have seen but one good case, — a woman 
admitted during the last hours of her life with what was evidently 
chronic parenchymatous nephritis. Only about 5 cc. of urine could 
be obtained. This was of a rather cloudy yellow color; no blood 
grossly. After standing for a few minutes it clotted to a solid coagu- 
lum. In the decomposing alkaline urine, such as occurs in alkaline 
catarrh of the urinary passages, masses of pus, mucus, and bacteria 
may be voided or may even plug the passages, and resemble fibrin 
casts. 

Fragments of tumors have also been found in the urine. 

Albuminuria. — Cases of albuminuria may be divided into the false 
and the true. By the false are meant those in which the urine, as 
secreted by the kidney cortex is normal, and the albumin is contrib- 
uted lower in the urinary passages, either as an inflammatory exudate, 
or lymph, blood, or chyle. By albuminuria in the following paragraphs 
is meant only the true, — that is, albuminuria due to some disturbance 
of the renal epithelium, especially of the glomeruli, not of the blood 
capillaries ; the latter are always permeable to albumin, and the great 
wonder is not that albumin should ever pass through the renal epithe- 
lium, but that it does not always. Over all the rest of the body exu- 
dates and transudates are always albuminous. In albuminuria occur 
together serum albumin and " serum globulin." (See page 218). 

Albuminuria without Definite Renal Lesion . — Concerning PHYSIOLOGI- 
CAL albuminuria, — that is, the constant presence of a proteid in 
normal urines, — the pendulum has swung several times. Posner, in 

113 See Kolisch and Burion, Zeit. f. klin. Med., 1896, Bd. 29, p. 374- 



THE UKLNE: ALBUMINUEIA 



225 



1884, first claimed the presence of serum albumin in all normal urines; 
this was believed in and then doubted, and again accepted on the basis 
of certain chemical tests for albumin. With the supposed demonstra- 
tion that these tests indicated rather a mucin or a nucleo-albumin, the 
physiological albuminuria was again doubted, until recent work, par- 
ticularly that of Morner and that stimulated by him, seems to have 
established beyond doubt the presence of a small amount of serum 
albumin, or, according to others, euglobulin, in practically all normal 
urines. 

With Spiegler's reagent it is hard to find a person whose urine is 
really albumin-free. The absence of true nucleo-albumin in the urine 
may be considered as proof that this " albuminuria " is physiological. 

If this is the case, there is no line between physiological and patho- 
logical albuminurias except that of amount. By " albuminuria " is 
now meant a condition in which serum albumin may be detected by 
the tests accepted in common use as standards, and the cases with small 
amounts of albumin which pass unnoticed by these tests and require 
special technique are not included. Hofmeister gives as standard that 
if Heller's test shows no ring in three minutes the urine is to be con- 
sidered albumin-free. 

Hence the question of albuminuria is similar to that of glycosuria, 
a very small amount of both bodies being normal, but disregarded 
unless increased to sufficient amount to give the tests accepted as cri- 
teria. The line, however, is an artificial one and very difficult to draw. 
This gives the teacher considerable difficulty in the medical school, in 
which the students are taught the very delicate tests, since each year 
a few discover a positive albumin test in their urine and are rendered 
very unhappy thereby. 

Concerning this proteid of normal urine, the demonstration of 
which requires very delicate tests or the use of large amounts of urine, 
see page 219. 

The above is the only correct use of the term physiological, al- 
though this is wrongly used for cases of albuminuria in the apparently 
healthy. By albuminuria in the following pages will be meant an 
amount which can be detected in the test-tube with a few cubic centi- 
metres of urine. 

But the so-called functional albuminuria is a different matter. 
The term " functional " Pavy used merely in contrast to " structural," 
in which case the albuminuria depended on anatomical changes in the 
kidney. In these cases ordinary tests are used and a small amount of 
urine, and concerning the presence and nature of the proteid there is 
no doubt. Senator considers that the albuminuria is truly " physio- 
logical " or " functional " when it is slight in grade, occurs in young 
men, is transitory, the further history of that person is negative, the 

15 



226 



CLINICAL DIAGNOSIS 



urine is otherwise normal, and its occurrence follows always an 
unusual and adequate cause, such as very severe muscular work by 
those not used to it. But these cases should be placed in a separate 
group and the term " physiological " used with caution. Such cases 
are normal men who, after unusual exercise, exertion, exposure to 
cold, nervous stress, or after unusually large proteid meals, show a 
temporary albuminuria. According to Senator the cause must be 
something unusual for that person, and later, if he accustom himself to 
this cause it will not produce an albuminuria. 

This form of albuminuria was first noticed among soldiers, many 
of the raw recruits showing albumin aftei-a forced inarch. It was first 
stated that 16 per cent, and later that 59 per cent. (Leube) »of these 
new soldiers showed a temporary -albuminuria. Later examina- 
tion of the same soldiers shows practically every one albumin-free 
(Flensburg). 

As further illustrations showing that the same may be true also 
of trained men, are the foot-ball players, in whom Macfarland 114 
found in practically every player after a game an albuminuria which 
lasted for the most part but three to four hours. Miiller 115 showed 
that eight of eleven bicycle riders after races showed albumin, and 
seven of twelve showed casts of all descriptions and renal epithelium. 
The urine was normal the following day. The same is true of ath- 
letes, mountain climbers, bicycle riders, foot-ball players, those persons 
who exercise severely the leg and thigh muscles especially to a degree 
beyond that to which they are accustomed, and later are able to stand 
an equal amount without the same result. We may say that it is only 
a question of limit ; practically every one can if he will produce albu- 
minuria, if he only over-exerts himself sufficiently. The most nor- 
mal man in every sphere of life must still observe certain limitations, 
and the question comes, Having overstepped these, can the albuminu- 
ria which results be termed " physiological " ? Of course, the limits 
for persons differ, and what is physiological for one is pathological 
for another, but the groups of cases now under consideration con- 
cern only those of the highest physical attainments, — trained athletes, 
young men picked for the army, etc. Macfarland's studies of the 
urines of twenty foot-ball players immediately after a game give 
excellent reasons for thinking that for a while *at least after severe 
exercise the kidneys are not in normal condition. In the urine of 
nineteen he found granular casts; in that of six, blood casts and red 
blood cells. 

In this same group Senator includes cases the relation of which to 
the normal bounds of the physiological it is more difficult to deter- 

114 New York Med. Rec., 1894, vol. xlvi. p. 769. 
u5 Miinch. med. Wochenschr., 1896, No. 48. 



THE URINE: ALBUMINURIA 



227 



mine. Among such are albuminurias following violent emotions and 
an unusually heavy proteicl meal. The latter, " alimentary albuminu- 
ria," is a form considered doubtful by some, that is, in the sense that 
the kidney merely excretes an excess of proteid as a part of its normal 
function to relieve the blood of superfluous constituents, as it does for 
glucose. Among soldiers, hence men under uniform conditions, Rapp 
found that 10.7 per cent, showed albuminuria after their mid-day 
meal. Experiments show that a large amount of certain proteids ( for 
instance, eight or more raw eggs) will in some apparently normal 
persons, but not all, cause albuminuria ; but the amount ingested must 
be excessive. After much smaller amounts the egg albumin can be 
detected in the blood-plasma. In nephritis cases small amounts are 
excreted through the kidneys. The output for normal men begins in 
about two hours and lasts four. 136 This is confirmed by animal ex- 
periments, but the demonstration that not only is egg albumin excreted 
as such, but serum albumin as well, as shown chemically and by the 
specific precipitines (it is only just to say that this method [precipi- 
tines] has not proved very satisfactory), suggests that the excess of 
proteid in the blood may have, temporarily at least, placed the kidneys 
in a pathological condition. An alimentary albuminuria is claimed for 
the new-born whose intestinal mucosa has not yet developed that im- 
permeability to foreign proteids which later is present, hence the albu- 
minuria when fed on cow's milk. 

Prolonged cold baths will cause albuminuria. Rem Picci 117 found 
from observations on one hundred and fifteen baths of thirty-five 
healthy men that three minutes at 12 0 to 13 0 C, or fifteen minutes at 
1 5° to 20 0 C. (none at 20 0 ), caused quite regularly a slight transitory 
albuminuria, minimal in amount, never lasting over twenty-four 
hours, with casts, and generally diuresis with increased urea and chlor- 
ide output. This he explained from reflex nervous influences from 
the skin. It is serum albumin in the urine. 

Mental over-exertion is also claimed as a cause in certain cases. 

There is special reason for the albumin to appear should several 
of these predisposing factors occur simultaneously. The intermittent 
nature of the albuminuria is no criterion, since a truly pathological 
case may intermit considerably ; but in all such cases must be empha- 
sized the appearance of albumin after a very unusual strain or occur- 
rence, and one adequate to explain its appearance ; also its very tem- 
porary duration. Senator considers that if the amount of albumin 
exceeds 0.4 to 0.5 gm. per litre it cannot be called "physiological." 

U6 For recent articles, see Ascoli, Munch, med. Wochenschr., 1902. No. 10, and 
Inouye, Deutsches Arch. f. klin. Med., 1902, Bd. 75; and on the opposite side of 
the question Umber, Berl. klin. Wochenschr., July 14, 1902; for the chemical side, 
Sollman and Brown, Jour, of Exp. Med., March 17, 1902. 

117 S. J., 273, p. 37, 1901. 



228 



CLINICAL DIAGNOSIS 



Another example of " physiological'' albumin is the albumi- 
nuria of the new-born. Often for the first eight or ten days there 
is a slight amount of albumin with hyaline casts, epithelial cells, and 
urates present. This is also present in the urine found in the bladder 
of still-born children, and therefore is not attributable to any changed 
circulatory or metabolic products after birth. Ribbert gave as an 
explanation that the kidneys at birth are really not quite " finished," 
but there still occurs a desquamation of epithelium of the capsules of 
the glomeruli, hence with the albumin occurs nucleo-albumin from 
these cells. 

The albuminuria of women in labor should be considered as 
physiological. Some find that in about 39 per cent, of normal cases 
this is present. It is attributed to the circulatory changes of the kid- 
ney due to the work, strain, etc. The condition of the kidney is doubt- 
less pathological, but the cause is physiological, and the albumin usually 
disappears at once. Little, 118 as the result of very careful work, con- 
cludes that albumin is present in the catheterized specimens of urine 
from about one-half of all pregnant women, being equally frequent in 
primiparse and multiparas. Casts occur with greater relative fre- 
quency in multipara?. During labor these percentages increase, espe- 
cially in primiparse. This may be due to the muscular work and in- 
crease of blood-pressure during labor. During the puerperium the 
percentage drops. 

" Albuminuria of adolescence" (Gull), " of puberty," "acci- 
dental albuminuria," " essential albuminuria," " physiological albumi- 
nuria," " Pavy's disease," " cyclic albuminuria of the apparently 
healthy," " postural," " orthotic," " orthostatic," and " intermittent 
albuminuria." This group of cases is of far greater importance and 
interest than the preceding. It is also a much larger group than has 
been suspected. These cases are discovered by army medical inspec- 
tors, by the examiners for insurance companies, and by the doctors 
to whom our neurasthenics apply for treatment. Insurance men 
say that of the " normal " persons examined while the temperature is 
above 90 0 or below o° F., 5 per cent, show albumin ; at other times, 
about 2 per cent. 

This group includes those persons enjoying reasonably good 
health, but whose urine either constantly or temporarily contains a trace 
of albumin. Their number is large, and they certainly can be divided 
into several groups, which classification it is convenient to use, al- 
though the present may strike entirely beyond the bounds of evidence. 
The above long list of names shows what features may predominate. 
Posner proposes the quite satisfactory term, " essential albuminuria," 
for the albuminuria is the one symptom common to all. 



Amer. Jour, of Obstet., vol. 1, No. 3, 1004. 



THE URINE: ALBUMINURIA 



229 



Of the group as a whole it may be said that it includes young- 
persons during adolescence or in the few following years, who are 
often not of best health, and not robust but anaemic, often children 
with a neurotic family history and with unstable vasomotor system, 
who sometimes give in their history such diseases as scarlet fever, 
diphtheria, et al., which would suggest a latent nephritis, who may con- 
tinue for years in good health or later show clear signs of Bright's 
disease. Common to all is the absence of other signs and symp- 
toms of kidney trouble, and if it is cyclic or intermittent the albumin 
appears in response to ordinary acts of our every-day life, that is, not 
to an unusual or adequate cause. In some cases it is said to follow 
walking or other exercise, in others a heavy meal. It is sometimes 
a family disease, three children in one family showing it (Lacour). 
In this group are included by some the albuminuria of masturbators 
and that following sexual excitement. In these cases it may be pres- 
ent only before rising in the morning. Some (Sir Andrew Clark 
and others) say this proteid is a secretion of the ureter or accessory 
glands. 

A diagnosis is possible only after long careful study of the in- 
dividual case, including past history and especially the physical signs 
on the part of the heart and eyes, and even then the autopsy may 
reverse the diagnosis. 

If there be good evidence of past renal disease or any cardiac 
features suggesting it, the case must be considered one of nephritis. 
The specific gravity, amount, sediment, etc., of the urine are im- 
portant in diagnosis. The intermittent nature of the output is no 
criterion, since this may be seen in true chronic nephritis ; nor does 
the presence or absence of casts help, since hyaline casts may occur 
whenever albumin does, and careful search shows them in the more 
truly physiological cases ; nor does the typical postural character, for 
this is seen in cases of acute nephritis after scarlet fever as it recedes 
( Knopf elmacher) and in cases of chronic interstitial nephritis and of 
waxy kidney. 

While one case may fall in any one or several of the following 
groups, we give the classification to emphasize the features which such 
cases present. 

The " albuminuria of adolescence" is a form separated by 
Leube from the one great group. It occurs between the ages of four- 
teen and eighteen years and then disappears. It may be explained by 
a renal insufficiency relative to the growing organism, the kidney not 
keeping pace with the physical growth and activity, together with 
instability of the vasomotor centres. In this group occur most 
of the cyclic or postural cases, not all, since some of these latter 
continue to adult life, and not all the cases of this group are truly 



230 



CLINICAL DIAGNOSIS 



postural. The element of heredity is very important. The cases 
reported by Lommel 1 19 would fall under this title, since the question 
of posture was little considered. Of 587 factory workers from four- 
teen to eighteen years old, 18.9 per cent, showed albuminuria once 
or many times, in small amounts and for the most part intermittent. 
Of sediment there was none, or at the most a few hyaline casts and 
fatty epithelial cells in the centrifugalized specimen. Of 130 pa- 
tients from the same class, but over twenty-five years old, only one 
showed albuminuria. Cardiac and vascular disturbances were com- 
mon. Posner emphasized sexual excesses at puberty as a common 
cause. Sutherland 120 emphasized the relation between this form and 
movable kidney present in one-third of his cases, and so common in 
children. 

Cyclic albuminuria is the most interesting of all. This form 
shows a remarkable daily cycle, the albumin being absent at night and 
when the patient is flat on his back, but appearing when he stands up. 
The terms orthostatic or postural are therefore more suitable. It is 
the history, extending over considerable time, and the negative physical 
examination which permit us to place these cases among the functional 
albuminurias. Other cases of albuminuria may be beautifully cyclic,, 
yet definitely pathological. Such is seen in cases of beginning nephri- 
tis, and during the convalescence it is, in fact, a very suggestive sign 
of Bright's disease. 

The rest of the cyclic cases may be subdivided : into those asso- 
ciated with vasomotor phenomena and with the neuropathic element 
predominating; those with circulatory derangement, as congenital 
floating kidney; and the hereditary form (Mix). As a rule, the 
albumin appears after rising, and reaches a maximum at noon or from 4 
to 6 p.m., then declines, disappearing from 8 to 10 p.m. If the 
patient change his habits, the cycle will change as well. Many cases 
bear little or no relation to meals. There is not only a cycle of the 
albuminuria, but also diminution in water output, and the sequence 
each time is, increase in pigments, of albumin, of uric acid, lastly, of 
urea (Teissier). While casts are rare, yet careful search will, as a rule, 
show them. The albuminuria may even be diminished by exercise and 
fatigue, hence is less at night after a hard day's work. Mix 121 has 
divided such cases into the intermittent and continuous, the terms 
applying to the periods over which the daily cycle occurs. In 
the continuous form the cycle continues for years, and if it ceases 
does not recur. These cases practically never develop in Bright's 
disease. The adults are neurasthenics with vasomotor paresis, and 

119 Deutsches Arch. f. klin. Med., 1903, Bd. 78, p. 541. 

120 Am. Jour, of the Med. Sci., 1903, vol. cxxvi. 

121 Ibid., 1904, vol. cxxviii. p. 307. 



THE URINE : ALBUMINURIA 



231 



the children in about 37.5 per cent, of the cases have a congenital 
movable kidney. 

There has been a great dispute whether such cases should be 
considered as pathological or not. They are rare. Other transitory 
albuminurias are certainly pathological; e.g., those of fevers, and 
even in these cases is there not always a subsequent history. Most 
writers warn against considering them as functional, since the duty 
of renal epithelium is to retain albumin, and when it does not do 
so something is wrong. Senator says the patients are chiefly young 
people at puberty of not the best health; they are anaemic, weak, 
and faint easily. Armstrong, 122 from the study of over three thou- 
sand school-boys, found this form in 12 to 15 per cent. It is found 
more in summer than in winter; heredity is often present; it is 
often associated with depression of spirits and fainting spells, espe- 
cially while the boy is standing idle, not when occupied; the boy 
is apathetic, with a heart subject to intermittent attacks of dilata- 
tion and palpitation ; it lasts only during puberty. Posner's case was 
well after seventeen years. Such may, perhaps, be considered as per- 
sons renally weak, hence like certain cases of glycosuria, and yet 
who give no subsequent history. Senator 123 still insists that the ma- 
jority of these cases are nephritis either at onset or during a latent 
case. Krehl, having followed several cases over a long period of time, 
considers that the absence of subsequent history of nephritis allows us 
to consider the condition harmless ; that these are not mild cases of 
Bright's disease. Broadbent 124 has never known a true case of this 
form to develop actual renal disease. In all the above cases the 
amount of albumin is small, the amount of urine normal, with the 
specific gravity normal ; a few hyaline casts are sometimes present ; 
in others no casts are found at any time after careful search; and 
there are no cardiovascular changes. The immediate cause is much 
in dispute. Possibly the most reasonable explanation will be one which 
associates the urinary findings with the rather marked changes in 
the renal circulation which follow changes in posture. Edel in three 
very interesting cases found that the albumin-free intervals (in the 
afternoon as a rule) were also periods of diuresis. He found that the 
amount of albumin varied roughly inversely to the amount of urine, 
and thought that diuresis was the chief thing to 1 strive for. He empha- 
sized the relation between the condition of the urine and that of the 
heart, the albumin being absent when the pulse was " full." This 
question is best studied by Erlanger and Hooker, 125 who found that the 

122 Brit. Med. Jour., 1904. 

128 Deut. Arch. f. klin. Med., December 8, 1904. 

124 Brit. Med. Jour., 1904. 

125 Johns Hopkins Hosp. Rep., vol. xii., 1904. 



232 



CLINICAL DIAGNOSIS 



amount of albumin varied inversely as the pulse-pressure (the differ- 
ence between the maximum and minimum arterial pressures), the 
albumin appearing when this is low. 

In other cases, however, originally considered as belonging to 
this group the continuance of albumin with the presence of casts and 
the appearance of subsequent cardio-vascular changes marks the case 
as one of B right's disease from the onset. 

The hypostatic albuminuria of splenic origin which occurs 
in some persons with enlarged spleens while recumbent, and is absent 
while erect, is, Rolleston thinks, the opposite of cyclic albuminuria. 
Since it is not seen in all with enlarged spleens nor in those with the 
largest, some other factor is necessary. The pressure on the left renal 
vein may explain it. It may resemble the albuminuria in the chronic 
passive congestion of mitral disease. 

Albuminuria Minima (Lecorche and Talamon). — Under this 
group are included cases with a constant trace of albumin, almost 
never 0.5 gm. per litre. The output is quite constant in amount, vary- 
ing little with the position of the patient, the time of day, diet, etc. 
For each case, however, there may be some factor which causes 
an increased output. Some such cases are quite certainly the result 
of a preceding acute nephritis, a residuum as it were. Their prog- 
nosis is uncertain 'and must be guarded, for some develop to true 
nephritis. Others remain the same for years with no further symp- 
toms. 

Under this group the French put the post-infectious cases, albu- 
minurie residuale, albuminuric paracellaires (or insular nephritis), 
albuminuric cicatricielle (due to imperfect healing, leaving a " scar ") ; 
also the albuminuria of adolescence, the hereditary form, albuminurie 
phosphaturique, and the albuminurie pregoutteuse. 

Intermittent albuminurias are those in which periods with 
albumin are followed by others with clear urine. This term does not 
include the cyclic or postural, which terms are limited to those with 
daily periodicity, while the periods of the intermittent may extend 
over weeks and months or years. The term' " intermittent " is more 
applied to cases of temporary albuminuria due to a known cause. 
These cases are usually of insidious nephritis, and give a history of 
some acute infectious disease. But one of the best illustrations is the 
albuminuria accompanying heart disease. These patients are admitted 
repeatedly with broken compensation and urine containing albumin 
and casts which soon disappear. 

The intermittent hereditary form includes, according to some, 
many cases of the albuminuria of adolescence, the cases showing none 
m adult life except in response to fairly adequate cause. 126 In some 
126 Dieulafoy, Loude, Arch. gen. de med., n. s., ii., 3, p. 257, 1899. 



THE URIKE: ALBUMINURIA 



233 



cases the parents had albuminuria during youth, while in others a 
neurotic family history is the only suggestive feature. 

Traumatic Albuminuria. — Transitory albuminuria follows injury to 
the brain, apoplexy e.g.; after injuries crushing the kidneys the albu- 
minuria and casts may continue for a long time with no other signs 
of nephritis. This may explain some cases of benign latent contracted 
kidneys (Stern, Curschmann). Menge 127 found that even bimanual 
palpation of the kidney in physical examination will in 15 of 21 cases 
cause a transitory albuminuria lasting usually from one to twenty- 
four hours at the most, and in some cases a slight hematuria. Any- 
thing obstructing renal venous flow, as in movable kidney during the 
crises, may cause albuminuria and cylindruria. 

Febrile Albuminuria. — During any acute fever, but especially pneu- 
monia, typhoid, malaria, acute articular rheumatism, grippe, or even 
tonsillitis, there may be a slight albuminuria, simultaneous with the 
rise in temperature and disappearing with its drop. In such cases the 
cloudy renal epithelium, the faintest grade of inflammation (Leyden), 
is considered the anatomical basis. The amount is usually small, but 
sometimes great. Hyaline and epithelial casts are sometimes found, 
but no other formed* elements indicating inflammation. In general it 
is only a matter of degree which separates these from true cases of 
nephritis. 

Under haematogenous albuminuria is included a very confusing 
group of non-febrile cases which show at autopsy no renal lesions, 
except, perhaps, slight parenchymatous changes. In this group are 
cases of purpura, scurvy, chronic lead or mercury poisoning, lues, 
leukaemia, cachexia, and anaemia in which the albuminuria is always 
slight and occurs only when these conditions are severe, cholaemia, 
glycosaemia, and following ether and chloroform narcosis. 

Strictly speaking, " haematogenous albuminuria" should mean one 
in which, either due to some alteration of a normal proteid of the 
blood, or because it is foreign, a proteid unsuitable for use is ex- 
creted. All cases with the possibility of the presence of a toxic in- 
fluence on the kidneys, for instance, lead, mercury poisoning, etc., 
should be excluded, since such would have a truly renal origin. It 
is true that foreign proteids in the serum are excreted, e.g., albumoses, 
egg albumin, peptone, casein, free haemoglobin, etc. Some consider 
that in all cases of albuminuria such is the case, an abnormal proteid 
or a normal one rendered unfit for further use being merely excreted. 
Yet in cases of true nephritis there is no evidence of a foreign proteid 
or qualitative change of the normal proteid. It is suggested, however, 
that quantitative changes either of proteids or salts could explain the 
albuminuria. But more probably the real cause is in the cells them- 
m Munch, med. Wochenschr., June 5, 1900. 



234 



CLINICAL DIAGNOSIS 



selves, the renal epithelium being exceedingly sensitive to changes in 
its nutrition, and that a true haematogenous albuminuria is not proved. 

The Nervous Form. — Epilepsy, apoplexy, tetanus, exophthalmic 
goitre, injuries to the head, delirium tremens, various psychoses, even 
neurasthenia and migraine may be accompanied by a slight transitory 
albuminuria. In some cases there are a few casts present. Interest- 
ingly enough in other cases only casts are to be found. YVe followed 
the urine of such a case in a boy fourteen years old with hysterical 
attacks. A very transitory albuminuria cannot be excluded, since the 
urine may not have been examined early enough. The cylindruria 
lasted for several weeks. 

Cases of closure of the ureter, retention of urine in the bladder, 
compression of the thorax, have been accompanied by albuminuria; 
digestive disturbances, as obstruction of the bowel | a reflex cause 
being assumed as in cases of strangulation of bowel or omentum; 128 ) 
acute diarrhoea, constipation, and liver disease are sometimes given as 
causes. In two-thirds of the cases the albumin disappears after the 
obstruction is relieved even though the bowel has been rendered gan- 
grenous. The cause is uncertain. It is probably not the absorption of 
any bodies, since in peritonitis, where there would be a similar absorp- 
tion, the albuminuria does not occur. Such cases are transitory. 

Albuminuria with Definite Renal Lesions. — In active renal congestion, 
as after exposure to cold, or in chronic passive congestion due to heart 
or lung disease, tumors, or pregnancy, albumin may be present, yet 
no other renal lesion found. As a rule the albumin is little in amount 
and this runs parallel to the amount of urine, while in the case of true 
nephritis the amount varies inversely as the amount of urine as a rule. 
In children albuminuria may accompany the simple hyperemia in diph- 
theria, e.g., which may then stop or develop into a nephritis. 

Organic Bright 's disease of all varieties is accompanied by albu- 
minuria at some time during its course. It is interesting that there 
is no parallelism between the amounts of albumin and the severity of 
the nephritis. In the chronic interstitial nephritis ending in uremia 
it may be present in traces. In other cases periods with traces may 
alternate with months when there are none. In general the rule is 
that the more acute the case the larger the percentage of albumin. In 
all cases it is. however, more a matter of percentage than of total 
albumin ; for to excrete a larger amount of urine with a lower per- 
centage of albumin is evidence of a better renal condition than pre- 
viously when the percentage was higher but the total output much 
smaller since the output of urine was diminished. In some cases 
definitely acute there may be no albuminuria. 129 In nephritis also the 

125 Neumann, Trans. Clin. Soc. of Lond., 1897, Bd. 30. p. 65. 
129 Herringham. Trans. Clin. Soc. of London, vol. xxxiv. p. 901. 



THE URINE : ALBUMOSURIA 



235 



percentage of albumin varies, as a rule, inversely to the amount of 
urine. The albumin is seldom present in amounts of more than I per 
cent. Sometimes it reaches 2 per cent., while in very rare cases 5 per 
cent, or, in one case, 8 per cent. Senator mentions a case of subacute 
nephritis with a percentage of from 6 to 8 per cent, over a period of 
some days. Cases with the largest amounts of albumin output are 
interestingly enough often due to lues. These cases of nephritis 
syphilitica acuta prsecox are rare, but between 20 and 25 are recorded. 
In Hoffmann's case the enormous albuminuria ran parallel to the luetic 
symptom and improved under mercurial treatment. 

Salkowski's case 130 is especially interesting. The urine had a 
specific gravity of 1056, and 7 per cent, proteid. On standing, there 
was deposited a rich white amorphous precipitate, not a coagulum, 
of a proteid giving reactions between globulin and an albuminate, and 
which after standing gave those of albumin. This same case on an- 
other day showed even 8.5 per cent, albumin (the blood contains but 
about 7.5 per cent, of proteid). 

The total output of albumin is seldom great, that is, more than from 
1 to 20 gms. The deleterious effects of the nephritis cannot be attrib- 
uted to the actual loss of albumin, since this loss, as a rule, can be 
easily covered by one good meal. In amyloid disease the amount of 
albumin may be great or very small ; as a rule from 0.5 to 0.05 per cent. 

This albuminuria varies much, there being definite waves in the 
output. At first indiscretion in diet increases it, probably by intensify- 
ing the acute element of the process, later a more liberal diet may 
improve the condition. In some cases it would seem as if meat were 
not as harmful as vegetables, perhaps due to the salts of the latter. 
The albumin is increased by the erect posture, but this does not explain 
its increase during the waking hours, since the same curve is pre- 
sented by patients who are semierect all the time as by those who can 
rest recumbent. Exercise of any kind, even massage (Edgren), in- 
creases the output. 

A pure milk diet sufficient to cover the heat-needs is injurious, 
causing even hematuria, and should be varied with other nitrogenous 
foods. 

" Hetero-albumosuria." Bence- Jones' Body. " Kahler's Dis- 
ease." " Myelopathic Albuminosuria of Bradshaw." — This body, 
which occurs in certain rare conditions in the urine in very large 
amounts, was supposed, from some of its chemical properties, to be- 
long to the hetero-albumoses. Some recent work, for instance that of 
Magnus-Levy who obtained it crystalline, showed that it is nearly re- 
lated to genuine albumin. Among other reasons for this is that its 
digestion products include all the primary proteoses except hetero- 
130 Berl. klin. Wochenschr., March 3, 1902. 



236 



CLINICAL DIAGNOSIS 



albumose. This throws considerable doubt on the belief that it is 
a primary digestive product itself. Lindemann concludes that while 
it cannot without objections be put in any group of proteids it 
is nearest the true albumins. Dechaume considers it a mixture of at 
least three proteids (or groups of proteids), — proto-albumose, dysal- 
bumose, and a body like hetero-albumose. In 1903 but about 35 well 
studied cases had been reported. All but one (Askanasy), and 
this a case of lymphatic leukaemia, were cases of multiple myelomata. 
In all cases there is extensive disease of the marrpw. Such cases run 
a rather acute course with a fatal termination in from one-fourth to 
one and a half years. 

The Bence-Jones' body is often present in large amounts, even 7 
per cent., but in the majority of cases it is below 1 per cent. Some 
cases are reported as intermittent (Boston). Coriat 131 reported a case 
with none in the urine, but with 4 per cent, in the pleural fluid. 

Reactions. — The specific reaction is that on warming there de- 
velops at a low temperature (about 6o° C, often 52 0 ) a milky, then 
heavy, sticky precipitate, which disappears for the most part and in 
some cases perfectly on bringing to a boil, and reappears on cooling. 
The urine must first be rendered acid with acetic acid. This being 
the characteristic reaction, the name suggested by Hugounenq for the 
condition " thermolytic albuminuria " (" albuminuric thermolytique ") 
is very appropriate. 

On adding nitric acid to the urine a heavy precipitate forms which 
is soluble on warming and reappears on cooling. 

The urine may be saturated with (NH 4 ) 2 S0 4 at ioo° C, filtered : 
the precipitate washed with saturated (NH 4 ) 2 S0 4 . The precipitate 
is then dissolved in water or dilute NaCl solution and the biuret test 
applied. The urine gives the biuret reaction directly. 

These are most striking reactions and attract attention at once. 
The precipitate appears at a moderately low; temperature, which de- 
pends on the amount present, also on the salt content of the urine. 
While a definite temperature cannot be stated, it is in general below 
6o° C. In the different cases the properties of the substance found 
have differed so much that either they were different bodies, or were 
not tested pure, or, and this is the present view, the varying amounts of 
salts and urea affected the tests. The urine may be turbid when voided. 

Boston 132 proposed the following test based on the large amount 
of loosely bound sulphur it contains. From 15 to 20 cc. of urine in 
a test-tube are mixed with an equal amount of saturated NaCl and 
shaken to a perfect mixture. Then 2 to 3 cc. of 30 per cent. NaOH 
are added and the tube shaken hard. The urine at the top of the tube 

131 Am. Jour. Med. Sci., 1903, vol. cxxvi. 

132 Ibid., 1902, vol. cxxiv. 



THE URINE: ALBUMOSURIA 



2H7 



is then heated to boiling and PbAc solution (10 per cent.) added drop 
by drop, heating after each drop. In one-half to one minute one gets 
a brown color turning to black. 

The output of this body is quite constant during the day and is 
not affected by diet, hence it is probably not a non-assimilated product 
of digestion. It seems to be formed in the bone-marrow. Some con- 
nection with the granules of the myelocytes and tumor cells is sug- 
gested. 

This albumose can be demonstrated in ascitic fluid, blood, and 
bone-marrow. 

Quantitatively the Esbach tube will give an approximate deter- 
mination. 

For recent literature concerning the nature of the substance the 
reader is referred to Simon. 133 

Albumosuria, " Peptonuria." — Under this term at least two differ- 
ent groups of bodies have been described, — the above-mentioned rare 
so-called 4k Bence-Jones' body,'' which because of its many reactions 
was counted with the primary proteoses, and a group of bodies having 
nothing in common with the above, formerly called peptones, a name 
based on Britcke's definition as a proteid not precipitated by K 4 FeCN 6 
and acetic acid. By " peptone" is now generally understood one not 
precipitated by complete saturation with (NH 4 ) 2 S0 4 (Kuhne), and 
judged by this standard these bodies are chiefly deutero-albumoses, 
hence the name " peptonuria" is less used and " albumosuria" has 
taken its place. But this criterion is not satisfactory (Neumeister) . 
As judged by it true peptone has been demonstrated in the albu- 
mosuria of croupous pneumonia, ulcer of the stomach, pulmonary 
tuberculosis and during the puerperium. It occurs always with 
albumose (the reverse is not true). 134 

In testing for the deutero-albumoses the urine should be albumin- 
free, and if this is not the case it should be made so by the Hofmeister 
method. Morner's body may be precipitated by basic lead acetate. 

An easy test is to saturate the urine with ammonium sulphate, a 
flocculent precipitate indicating albumose. 

A good preliminary test for the deutero>-albumoses is that of Hof- 
meister. To the urine is added one-fifth volume of concentrated 
acetic acid and then phosphotungstic acid. If the urine remains 
clear after standing for some time, these bodies are not present, 
while a milky cloud at once or in about ten minutes indicates them. 
This test is valuable if positive, but not if negative. 

The biuret test is that usually used. According to Hofmeister the 
albumose is first precipitated with tannic acid or phosphotungstic 

133 Am. Jour. Med. Sci., 1902, vol. cxxiii, p. 939. 

134 Ito, Deutsches Arch. f. klin. Med., 1901, vol. lxxi. 



238 



CLINICAL DIAGNOSIS 



acid. The precipitate is dissolved in a little water and the concentrated 
solution tested. NaOH or KOH are added in excess and then very 
dilute CuS0 4 . Deutero-albumoses are indicated by a violet-red color. 
It may be necessary to filter off the precipitate of Cu(OH) 2 . If this 
test be applied to the urine directly, the color obtained is a red or a 
reddish-brown, the violet being obscured by the color of the urine. 
The test may also be performed as a contact test, the urine being 
rendered alkaline and then carefully superimposed by a dilute CuS0 4 
(5 cc. of a saturated solution to 1 litre of water). 

For a positive test the albumose must be isolated. This may be done with 
phosphotungstic acid, which will allow 0.1 gm. per litre to be detected, or tannic 
acid, somewhat less delicate. Albumin and " nucleo-albumin" must first be removed 
with basic lead acetate. 

Salkowski's method. This was designed to detect small amounts of albumoses. 
To 50 cc. of urine in a beaker is added 5 cc. of concentrated HC1 or acetic acid. 
It is then precipitated with phosphotungstic acid and warmed over the free 
flame; the precipitate collects as a tough resinous mass at the base of the beaker. 
The supernatant fluid is decanted and the precipitate washed with distilled water 
a few times (twice), being careful that none be lost. On the precipitate is then 
poured 8 cc. of water plus 0.5 cc. of NaOH (sp. gr. 1.16). It dissolves readily. The 
blue solution is then warmed until clear. More NaOH is added if necessary, 
since the mixture is often of a dirty grayish-yellow color and cloudy. The solu- 
tion is then cooled and the biuret test applied by adding in a test-tube a few 
drops of 2 per cent. C11SO4. Before applying the biuret test Sahli recommends that 
the colored fluid be cleared with BaCk Urobilin, if found with the spectroscope, 
must be removed, and may be extracted with amyl alcohol. Sahli says that it 
is completely enough precipitated with CaCk The test may be performed in five 
minutes. The small amount of urine used minimizes the danger of mistake with 
" nucleo-albumin." 

Another method is as follows: To the urine is added 0.1 volume of concen- 
trated HC1, then PWo acid, again HC1, and again PWo acid, until neither gives 
any more precipitate. The urine is then filtered at once before uric acid pre- 
cipitates. The precipitate is washed on the filter with H2SO4 (3 to 5 volumes 
concentrated H 2 S0 4 in 100 cc. of water) until the wash-water runs colorless. The 
moist precipitate is then rubbed up with dry Ba(OH) 2 in excess. A little water 
is then added and the warm solution filtered. If heated too much the solution 
becomes dark. The peptone solution is always yellow. The biuret test is then 
applied and a red color obtained if albumose be present. In this case the test is 
best performed as a contact test, since the BaSO* precipitates and settles. 

Hammarsten recommends the following method, which has been modified by 
Bang : Ten parts of urine plus 8 parts of saturated ammonium sulphate are heated 
to boiling for a few seconds. The hot fluid is then centrifugalized from one-half 
to one minute and decanted. From the precipitate is extracted the urobilin with 
alcohol. The residue is then taken up with little water, heated to boiling and 
filtered. This removes the albumin. It is then shaken out with chloroform to 
remove the last trace of urobilin. The chloroform is then pipetted off and the 
water tested with the biuret for the presence of albumose. This is a very practical 
clinical method. 

Alder, 135 after criticising all the preceding, recommends the following as more 
accurate. Albumin if present is removed by trichloracetic acid (15 per cent). 
To 6 to 10 cc. of urine in a test-tube are added 1 to 2 drops of HC1 till acid, then 
5 per cent, phosphotungstic acid till complete precipitation. The fluid is then 
centrifugalized for a few seconds. The supernatant fluid is poured off, the sedi- 

133 Berl. klin. Wochenschr., 1899, pp. 764, 780. 



THE TJKLNE 



239 



ment suspended in absolute alcohol, and again centrifugalized. This is repeated till 
the sediment and the alcohol (colored yellow with urobilin) are white and clear. 
The sediment is then suspended in water, strong NaOH added, the fluid shaken till 
all blue color disappears, then the CuS0 4 is added. 0.2 gm. per litre can be detected. 

Occurrence. — The deutero-albumoses may occur either alone or 
with albumin. In cases of nephritis the albumose is said to accom- 
pany the albumin. It may however precede the albumin or continue 
after it has disappeared. The reason for this is not known. Since 
the urine contains a pepsin-like ferment the formation of albumose by 
the digestion of albumin may be suspected. 

Hematogenous Albumosuria. — Many think that this group includes 
nearly all cases. When there is considerable albumose in the blood 
some is excreted in the urine, but not when the amount in the blood 
is small. The source of this albumose is thought to be disintegrating 
cells. These may be blood cells, as in leukaemia, scurvy, purpura, dur- 
ing the absorption of hemorrhage, during the action of a hemolytic 
poison, etc. Or they may be tissue cells destroyed by disease or by 
some toxine. The occurrence of albumosuria during pregnancy is 
interesting. That during the puerperium is ascribed to the involution 
of the uterus, and that after the death of the foetus to the maceration 
of the infant, but it occurs also in some cases of normal pregnancy. 

Enterogenous albumosuria is seen in cases of gastric or intestinal 
ulcer, as, e.g., in intestinal tuberculosis. In such cases small amounts 
of albumose ingested, e.g., somatose, will give a positive test; nor- 
mally larger amounts are necessary (alimentary albumosuria). Some 
consider that if following the ingestion of from 40 to 60 gms. of albu- 
mose this body be found in the urine it is in favor of a gastric or 
intestinal ulcer. 

In nephritis, especially luetic, albumosuria occurs. The " hepatog- 
enous " form occurs in acute yellow atrophy, cirrhosis, cancer, ca- 
tarrhal jaundice, and phosphorus poisoning. The " febrile " form 
occurs in fevers, especially the infectious; rheumatism, septicaemia, 
typhoid, phthisis, gangrenous processes, measles, scarlet fever, erysip- 
elas, and smallpox, especially as the temperature falls. It occurs in 
mental diseases and paralyses. " Pyogenic albumosuria " is supposed 
to be due to the absorption of an exudate, as in pneumonia during 
resolution, in empyema, bronchiectasis, epidemic cerebrospinal menin- 
gitis, abscess, and osteomyelitis. Gangrenous processes anywhere 
may cause it, also cancers of any organ. 

The common element in most of these conditions is the breaking 
down of some tissue or exudate, i.e., increased catabolism such as oc- 
curs in all fevers and in cancers (Aldor) or exudates. 

There are certain sources of albumose which should always be 
excluded ; as, for instance, spermin and secretions of the 'accessory 



240 



CLINICAL DIAGNOSIS 



genital glands ; the foods, since on a milk diet in nephritis it is claimed 
that the products of digestion are absorbed and excreted unchanged; 
and lastly, that due to technique in removing albumin from the 
urine. Clinically, the deutero-albumoses are important only when the 
urine is albumin-free. In albuminuria it may nearly always be dem- 
onstrated and the question arises whether it was preformed or formed 
from the albumin by the technique. The amount formed in this way, 
however, if the work be done well should be very small. 

It has very little clinical value, since it has such a wide occurrence. 
It could be of value, however, in a case of suspected abscess (e.g., of 
the appendix, brain, or an empyema) ; or in the differential diagnosis 
of tuberculosis and epidemic cerebrospinal meningitis. The amount is 
always small when compared with that of the Bence-Jones' body. 

Haematuria. — This may be a symptom of the following condi- 
tions : 

( 1 ) General diseases : the malignant forms of acute specific 
fevers, especially smallpox, typhoid fever, malaria; in leukaemia oc- 
casionally; in the so-called hemorrhagic diathesis, haemophilia, 
scurvy, morbus maculosus Werlhofii, and the purpuras. In the latter 
diseases the process may be limited to the kidney. 

(2) Renal causes, acute and chronic congestions, and inflamma- 
tions of the kidney; all nephritis cases at the onset, there being one 
form called the " hemorrhagic" form. Those due to turpentine, car- 
bolic acid, and cantharides especially have an hemorrhagic onset. In 
purulent nephritis traces only of blood may be present. The chronic 
parenchymatous, Weigert considered always hemorrhagic, hence small 
amounts of blood in the urine may always be expected. In amyloid 
disease there are few or no red blood-cells. In chronic passive con- 
gestion due to different causes there may be blood in the urine. In 
renal infarctions it may be considerable, but that is rare ; in new 
growths of the kidney sometimes the haematuria is profuse; at the 
onset of tuberculosis, especially when the papillae are involved ; in 
cystic kidneys, renal calculus, and, lastly, parasitic diseases of the 
kidney, especially filaria, echinococcus and the distoma haematobium. 
In congestion due to venous thrombosis, e.g., of the new-born, haema- 
turia is said to be a common symptom. 

(3) It is also found as the result of lesions or diseases of the 
urinary passages, as stone in the ureter, tumors and ulcers of the 
bladder, parasites of the bladder, calculi and ruptured veins ; in ure- 
thritis. 

(4) In trauma of any part of the urinary tract from the kidney 
down. 

(5) And lastly an interesting group with no known lesion; the 
so-called " Gull's renal epistaxis" or " essential renal haematuria," or 



THE UEINE: ILEMOGLOBINUKIA 



241 



" angioneurotic hsematuria," or " renal hemophilic," is a rare disease 
of middle adult life, often unilateral. In certain of these cases angio- 
mata of the kidney have been found, in others none, and nervous 
causes are suspected. Some of these cases recover without further 
treatment ; others after treatment of the nervous system, while others 
after a nephrotomy, or nephropexy or simple exposure of the kid- 
ney. 136 

In women the vagina as a source must always be excluded. 

More recent work with microscopic examination throws some 
doubt on the normal nature of these kidneys. Eshner 137 collected 48 
cases of unilateral renal hsematuria, most of which had been diagnosed 
as calculus or cancer. Since then other interesting cases have been 
reported. A diagnosis of unilateral hemorrhagic nephritis was made 
in Stich's case. 138 In Schiiller's case the kidney looked normal, but 
microscopically chronic parenchymatous nephritis was found. 139 

The term " hsematuria" is used only when blood is grossly visible. 
The urine is always turbid, of a light smoky to a bright red or 
blackish-brown color. Microscopically are found the red blood-cells in 
various conditions of preservation, and other elements according to 
the cause. In renal hsematuria clots are seldom present, the urine and 
blood are homogeneously mixed hence in equal amounts in the two- 
glass test, while in cases of hemorrhage from the bladder the second 
glass will contain the more blood, and if the bladder be washed out 
the washings will be blood-stained, while in renal cases, clear. In 
acute exacerbations of a chronic parenchymatous nephritis especially, 
the amount of blood in the urine may be considerable. Clots are pres- 
ent in rare cases, as when large vessels of the kidney rupture, or in 
cases of aneurisms, trauma, or varices. In a case in the ward recently 
a clot four inches long, a cast of the ureter, was voided. Such clots are 
more common in cancer than in calculus. 

Gerhardt thinks that the blood-cells from the kidney are more 
spherical, more leathery in color than usual, while all the morpholog- 
ical elements from the kidney, the casts and epithelial cells, are yellow- 
ish-brown. In renal hsematuria are found also casts of various kinds, 
blood-casts, or casts with red cells attached, and renal epithelium, 
showing parenchymatous lesions. Albumin will also be present. It 
is. generally believed that if the blood be not from the cortex and the 
urine allowed to settle, the clear supernatant fluid will be albumin- 
free. 

Hemoglobinuria is the result of hsemoglobinsemia, or the destruc- 

136 Stavely, Johns Hopkins Hosp. Bull., March, 1893. 

137 Am. Jour. Med. Sci., 1903, vol. cxxv. 

138 Mitth. aus d. Grenzgeb. d. Med. et Chir., 1904, Bd. 13, p. 781. 

139 Wien. k'lin. Wochenschr., 1904, No. 17. 

16 



242 



CLINICAL DIAGNOSIS 



tion of red blood-cells within the blood-stream in such numbers that 
the body cannot warehouse the pigment, which is therefore excreted 
by the kidneys. This occurs when about one-sixtieth of the total hae- 
moglobin is set free. It may follow various blood poisons; as potas- 
sium chlorate, pyrogallic acid, CO, naphthol, AsH 3 , etc. ; or the 
poisons of fevers, — -scarlet fever, typhoid, yellow fever, especially ma- 
laria, and lues ; or severe burns, exposure to cold, and the transfusion 
of foreign serum. It may occur during pregnancy (Brauer), as an 
epidemic fever of the new-born, in certain cases of nephritis, and after 
severe intra-abdominal hemorrhages. 

Curry 140 emphasizes the point that in "black water fever," so 
commonly supposed to be of malarial origin, evidence of malaria is 
not always present before or after death. The black water fever due 
to malaria may later recur after an ordinary dose of quinine. 141 The 
urine always contains albumin, and the albuminuria may precede or 
follow the haemoglobinuria. (This proteid is said to arise from the 
red blood-cells. ) This preceding albuminuria is a good answer to the 
theory that it is the irritation by the haemoglobin which causes this 
condition. Again, this idea of the origin from a haemoglobinaemia, 
although probable, does not rest on a very firm basis, for, as Senator 
says, haemoglobinaemia has never been proved in the hemoglobinuria 
due to infectious diseases or hemorrhagic nephritis, while in two cases 
of hemoglobinuria it was surely absent. 

The paroxysmal hemoglobinuria is a condition which has at- 
tracted considerabe attention. This is a rare condition of adults which 
occurs in attacks after exposure to cold or exertion, and which consists 
of haemoglobinuria often preceded by fever and chills, and pain in the 
lumbar regions. The output o>f haemoglobin continues for one or two 
days or less. The excretion is usually preceded by a haemoglobinaemia, 
but in rare cases this has been missed. 

The cause for this has been much in dispute. Some claim a hemolytic action 
of blood-plasma, " an increased number of complements," others a chemical 
toxine, others a mechanical injury of the red blood-cells, and in the circulation 
shadows are found, while others think the cause is in the kidney. Senator thinks 
this latter is to be considered in many cases. It is of interest that 23 of 77 cases 
gave a history of lues. The urine is red or dark brown ; spectroscopically is found 
methaemoglobin alone or with haemoglobin ; microscopically are found amorphous 
blood pigment in masses or casts, or even crystals of haematoidin ; few or no red 
blood-cells will be found, and if present they are so few that they cannot explain 
the pigment ; often hyaline and granular casts and renal epithelium are present ; 
sometimes many calcium oxalate crystals also ; albumin is always present, and 
often bile pigment, but, it is said, no bile acid. As the haemoglobin disappears 
the albuminuria will continue for a short time. During the attack will be found 
in the blood often shadows of red blood-cells, an increase of leucocytes, amorphous 
masses of pigment, and a great many platelets. Sometimes the haemoglobinaemia 

140 Jour. Am. Med. Assoc., May 3, 1902; Brem, Jour of A. M. A., Dec. 8, 1906. 

141 Nansen, Brit. Med. Jour., May 16, 1903. 



THE UKLNE: BLOOD 



243 



can be seen even grossly, the plasma having a reddish or a ruby-red color. It is 
doubtful if the isotonicity of the blood is changed. Degenerations in the red blood- 
cells are common, and other points indicating their lowered resistance, for instance 
their resistance against shaking and against CO2. Donath 142 was unable to show 
any lowered resistance of the cells to any mechanical influence. 

The immediate causes are various ; among them are excessive exercise or 
mental excitement. Cold is the most potent, and the patient may produce it by 
plunging his hands into cold water. It may also be produced locally by tying a 
string about one finger. Homburg's patient 143 showed it after an involuntary 
cold plunge of three minutes' duration. 

In hemoglobinuria the urine may be clear, but it is usually more or 
less clouded by haemoglobin casts, amorphous masses of pigment, and 
casts from the associated nephritis. If it be sedimented, the super- 
natant urine is a clear blood-colored fluid, and in the sediment so 
few red blood-cells that they could not possibly explain the amount 
of haemoglobin. The urine must be tested fresh to determine the 
difference between these two conditions, since the red blood-cells will 
so quickly go to pieces, freeing much haemoglobin and leaving an 
abundant grayish-brown albumin-rich sediment, in which may be seen 
the stromata of the laked red cells. Stempel reviews the literature to 
date in a splendid resume. 144 

Chemical Tests. — These, apart from the spectroscopic, are the 
same for haemoglobin and its many modifications, and whether intra- 
cellular or not. This last point can be tested only by microscopic 
examination. 

( 1 ) An ordinary heat-acetic acid albumin test is made. A brown 
coagulum forms which usually swims on the surface. If this be 
shaken with acid alcohol (H 2 S0 4 ), the clot is decolorized. The color 
depends on the amount of haemoglobin present. This test is not very 
delicate. 

(2) Heller s Test. — A test-tube is filled half-full of urine, about 
five drops of NaOH added to make strongly alkaline, and then 
warmed to form haematin. A brownish red or bloody precipitate 
results of the precipitated phosphates and carbonates of the alkaline 
earths which carry down the haematin. If the urine be already alka- 
line, the phosphates of the alkaline earths may already have precipi- 
tated, and hence the test fail, in which case it is necessary to add a 
certain amount of normal urine in order to supply these salts. 

This test is very delicate, indicating 1 cc. of blood in 1 litre of urine. If the 
fine red blood-color of the precipitate is not evident since the urine is dark or 
jaundiced, the precipitate should be filtered off, and dissolved in acetic acid; a red 
solution is obtained which decolorizes gradually in the air. This red precipitate 
has by reflected light a greenish tinge. If but little haematin be present, the pre- 

143 Zeitschr. f. klin. Med., 1904. 

143 Ibid., vol. liii. 

144 Zentralbl. f. d. Grenzgeb. d. Med. et Chir., 1902, vol. v. pp. 177, 267. 



244 



CLINICAL DIAGNOSIS 



cipitate should be dissolved in acetic acid and the residue of this used for the 
Teichmann's test. Similar red precipitates may be obtained after the ingestion 
of senna, rhubarb, or rhamnus. The urine, however, is yellow at first, and on the 
addition of the sodium hydrate becomes red. The phosphate precipitate, if dis- 
solved in acetic acid, gives a lemon-yellow solution, which changes on exposure 
to the air to a violet. Haematoporphyrin and other pathological pigments may 
give a red precipitate, but the spectroscope will quickly indicate the difference by 
showing the alkaline haematin spectrum. If but a trace of blood be present the 
urine is first made alkaline with NHtOH and then precipitated with tannic acid. 
The precipitate is used for the hsemin crystal test. 

(3) Teichmann's HCl-Hcemin Test. — The precipitate obtained by 
either of the preceding tests, or, better, a tannic acid precipitate, is 
filtered, washed, and dried in the air. A very small granule of the 
dry precipitate is put on a slide with one granule of NaCl and a few 
drops of glacial acetic acid. The cover-glass is then put on. The 
specimen is then warmed over a small name so that the acetic acid 
steams. The acid is constantly renewed. When the acetic acid sur- 



Fig. 31. — Haemin crystals. X 400. 

rounding the granule is stained a brownish color, the heating is dis- 
continued and the slide cooled very slowly. The characteristic crystals 
of hsematin may soon be seen with the microscope. 

This test requires care. The reasons it so often fails are that the specimen is 
heated too hot (a simple steaming is sufficient), or that the acetic acid is not suffi- 
ciently renewed, or the slide is cooled so rapidly that it forbids good crystallization. 
Good crystals may be obtained if the specimen is not heated at all but allowed to 
stand for twenty-four hours. 

(4) The tannic acid precipitate mentioned in test (2) may be 
ashed on a platinum-foil, the ash dissolved in a few drops of hot HC1, 
this diluted and filtered and tested with the potassium ferrocyanide 
solution. 

(5) The Guaiac test (Schonbein-Almen test) is very delicate. The 
urine is overlaid carefully with a mixture of equal parts of Guaiac tinc- 
ture (alcoholic solution of resina Guaiaci, 1 to 5) and old oxygenated 
oil of turpentine. The turpentine should be exposed to the air for some 



THE UBLN E 



245 



time, that it may be well oxygenated; the Guaiac tincture should not 
be exposed to the sun or air, and should be kept in a colored bottle. 
These solutions when mixed should show no blue color. The urine 
is superimposed with this, and if blood be present an intense blue ring 
appears at the line of separation. 

The urine must be acidified with acetic acid if necessary. This test is so deli- 
cate that it may be positive when the spectroscopic test is negative. Pus need not 
be excluded unless the above solutions have not been properly kept. The test 
should always be controlled with a fluid known to contain blood. The test is not 
absolutely positive, since other bodies will give it, yet it always has a negative value, 
since if negative no blood is present. 

Spectroscopic. — The student should be well trained in the use of 
the spectroscope. The blood spectra which are important are those 
of oxyhemoglobin, reduced haemoglobin, and methaemoglobin. In the 
case of the urine a mixed spectrum may usually be expected. If 
the blood is fresh, that of oxyhemoglobin will predominate, but in 
hemoglobinuria, or in nephritis, methaemoglobin. Bacteria will oxi- 
dize the last two to oxyhaemoglobin. The urine should be diluted if 
necessary, and must be clear. 

Very small amounts of blood-pigment are detected as follows 
(Hoppe-Seyler) : To 100 cc. of urine is added an albumin solution or 
an albuminous urine. This is heated, that a good coagulum may form, 
the precipitate washed, pressed out, and rubbed up with alcohol which 
contains a little H 2 S0 4 . This is then warmed and filtered. The 
filtrate after treating with NaOH and (NH 4 ) 2 S gives the bands of 
haematin. 

Methaemoglobin. — Many previous observations of this are not re- 
liable, since only a single spectroscopic examination was made, and 
haematin may have been mistaken for it. It is present in all fresh 
urines containing blood, although later it may be oxidized to oxyhaemo- 
globin. For its detection the spectroscope is necessary, but not alone 
the spectrum of neutral methaemoglobin, which may be confused with 
haematin, but ammonia must be added and the spectrum of alkaline 
methaemoglobin obtained. This spectrum may be confused by other 
bodies which give bands or which darken the field as bile or urobilin. 
One must be careful not to dilute too much, since it is easy to pass the 
point at which the lines are seen. 

Urobilin or bile-pigment may be removed with basic PbAc, the 
haemoglobin remaining in solution, but methaemoglobin will be precipi- 
tated. In case red blood-cells are present, water should be added in 
sufficient amount to lake them. If no absorption bands are seen, or 
they are very faint, the haemoglobin may be transformed to reduced 
haematin, whose spectrum it is easier to study. This reduction is best 
done with (NH 4 ) 2 S, or with NaHSOg and zinc, for only a short 



246 



CLINICAL DIAGNOSIS 



time, else the albumin will be precipitated. The spectrum of reduced 
haemoglobin is fainter than that of oxyhemoglobin. If a few drops 
of concentrated NaOH be added, haematin is produced. 

Hasmatoporphyrin. — Hsematoporphyrin, an iron-free derivative of 
haemoglobin, is present in the normal urine in very slight traces, but 
sometimes in very large amounts. Sulphonal is one of the most im- 
portant causes of the excretion of large amounts of this body. It is 
present in larger amounts, however, in cases of rheumatism, pericar- 
ditis, Addison's disease, paroxysmal haemoglobinuria, cirrhosis of the 
liver, pneumonia, and haematemesis. Some have considered that for 
the diagnosis of liver disease the increase is important. It is increased 
in lead poisoning. It is also increased in acute infectious diseases and 
in various forms of tuberculosis. Its presence is definitely proven 
only by the spectroscope. 

The color of the urine is sometimes deceptive. This is especially 
true of the cases of lead poisoning. In other cases it is dark brown- 
ish-red, cherry-red, or Bordeaux-red, varying with the amount of this 
pigment. " Port-wine " color is a common term. 

About 40 fatal cases of haematoporphyrinuria have been reported, 
chiefly in women, following the use of sulphonal. Trional and tetronal 
also cause it. 

The cause of this haematoporphyrinuria is not known. Some claim that lead, 
sulphonal, etc., have a direct action on the red blood cells ; others that they cause 
hemorrhages into the gastric mucosa, that the blood pigment in these is changed by 
the gastric juice to hsematoporphyrin which is absorbed and excreted. In other 
cases the one trouble is said to be a lesion of the renal epithelium. In haemoglo- 
binuria there is a preceding haemoglobinaemia, as a rule, but a haematoporphyrinaemia 
has not yet been proved. 145 

Pal 146 reports a case of paroxysmal haematoporphyrinuria with " black " urine, 
with symptoms similar to those of paroxysmal haemoglobinuria, and due, he thinks, 
to lues. 

Garrod 147 collected 12 cases not due to sulphonal. Nearly all of 
these patients were men, and the condition lasted years without bad 
symptoms. The generally accepted opinion is that the condition is 
due to perverted catabolism of haemoglobin rather than to increased 
destruction of red cells. 

SEDIMENTS 

Preservation of the Urine. — To study the sediments, especially the 
organized, it is best that the urine be examined while perfectly fresh. 
Casts will disappear to a certain extent in any urine, especially if the 
patient receive the organic salts as diuretics. We often see the urine 
alkaline and all casts gone one hour after voiding. The urine is best 

145 Ruedy, Am. Jour. Insanity, October, 1899. 

146 Centralbl. f. inn. Med., 1903, vol. xxiv. p. 601. 

147 Lancet, March 5, 1904. 



THE UBINE: SEDIMENTS 



247 



centrifugalized. In case the immediate examination is impossible, or 
a centrifuge is not at hand, the urine may stand in a conical glass, the 
cavity of which ends at a sharp point, or may be filtered through a 
filter paper and the last drops examined. A drop of the sediment is 
drawn up into a pipette; the outside of this is then wiped off- and a 
drop blown onto a glass slide. In case there is very much sediment 
in the glass, the components of the different layers will vary con- 
siderably, since their specific gravity is so varied, and so the sediment 
must be first well mixed or several specimens examined. 

To preserve the urine from bacterial action during long sedimenta- 
tion a piece of camphor may be used, or one-fifth volume of I to 
200 chloroform water, or one-fifth volume of saturated borax solu- 
tion, which prevents the precipitation of the urates and preserves the 
cells, while it does not coagulate the albumin. A few drops of forma- 
lin are really best, but this may add to the sediment a component of 
its own. One cc. of pure chloroform, so valuable in the preservation 
of urine for chemical work, is not to be recommended. Thymol is 
fairly good. It is very important to use a clean pipette since mistakes 
are often made by using one containing the elements of a previous 
sediment. In case the bacteria are the subject of study it is well to 
add two volumes of alcohol, which by lowering the specific gravity 
hastens the sedimentation. 

To preserve sediments for a long time the urine is centrifugalized 
and the supernatant fluid poured off. To the sediment may then be 
added chloroform water to preserve crystals, or formalin to 1 to 2 
per cent, to preserve casts and formed elements. They keep only 
fairly well. Of the crystals, the phosphates, carbonates, and ammo- 
nium urates keep well; calcium oxalate poorly, uric acid never 
well. 

The student should be early taught that there are very few sedi- 
ments which may be recognized beyond doubt from their appearance 
alone, hence the value of microchemical tests with acids, alkalies, 
Lugol's, stains, etc., which may be drawn under the cover by applying 
a piece of filter paper to the edge opposite to the drop of reagent. 
If few casts are present the surface of a large slide is covered by the 
urine and no cover-glass used. 

There is one peculiarity of crystalline sediments worthy of men- 
tion, — that the crystals tend to belong to one system; that is, the 
crystals of one salt are usually similar ; they are nearly all of the 
same regular or irregular form; all the uric acid crystals may be 
hexagons, all of calcium oxalate ovals, all the triple phosphate flat 
plates, etc. 

Another peculiarity is the relative infrequency of crystalline sedi- 
ments in women's urine. 



248 



CLINICAL DIAGNOSIS 



The sediments have been divided into the organized and unor- 
ganized. By the former are meant tissue constituents, casts, bacteria, 
and formed elements from the urinary or communicating organs. 

The reaction of the urine may often be detected from the gross 
sediment; when acid this is granular, when alkaline, mucoid. Speci- 
mens should be examined when made, since if allowed to dry even a 
little the crystals which separate are quite confusing. 

Unorganized Sediments. ( i ) Urates and Uric Acid. — A precipita- 
tion of urates occurs in any concentrated acid urine, especially on a 
cold day, much to the distress of mind of some persons. The urine 
first presents a very milky appearance, and the sediment then settles 
on the bottom and sides of the glass, forming a heavy voluminous 
mass. The color of the precipitate will vary from a yellow to a bright 
rose-red. It is soluble in acids with the subsequent precipitation of 
uric acid, and in alkalies. It is easily soluble on warming. While 
common in any concentrated scanty normal urine, it is especially so 
in certain fevers, chronic passive congestion, pneumonia, and rheuma- 
tism, seldom in nephritis or in albuminous urines. 

One of the most remarkable crystal forms are the long branching 
rods like huge yellow bacteria, which disappear on warming. 

This precipitate is said to be the quadriurates (Roberts), — MH- 
UU, which are formed by the action of MH 2 P0 4 on the biurates, 
MHU; if in sufficient concentration they are precipitated, The 
quadriurates in solution are easily decomposed to biurate and uric acid, 
the latter precipitating as little bright red so-called red pepper gran- 
ules on the sides of the glass. This will be the only sediment in case 
the quadriurate is not in sufficient concentration itself to precipitate. 
In the urate sediment are found also calcium oxalate crystals, and, as 
ammonia is soon formed, a certain amount of the acid urates will be 
dissolved, some will be transformed to ammonium urate, hence in the 
same sediment may occur ammonium urate, the so-called quadriurates, 
uric acid and calcium oxalate, and even a few triple phosphate crystals. 
This transformation occurs progressively from above downward. 

This explanation of Roberts is so satisfactory that it is unfortunate that it has 
little evidence behind it. One thing is quite certain, that the precipitation of the 
urates is the result of a chemical transformation of the salt, since it precipitates 
in the cooling urine too slowly to be due to this alone, and warming the urine to 
the previous temperature does not redissolve it. Also during its formation the 
acidity of the urine is said to increase. 

Microscopically, the acid urate sediment consists of very fine gran- 
ules in clusters of a yellow to a reddish-brown color which disappear 
on warming. On the addition of a little acetic acid the subsequent 
crystallization of uric acid may be watched. 



THE "URINE : SEDIMENTS 



249 



Ammonium Biurate. — Ammonium biurate (see Fig. 32) is the 
only urate sediment which forms in an alkaline urine. It may also 
form while the urine is very faintly acid. It occurs with the acid 
urate sediment after the reaction changes ; also with amorphous phos- 
phates and triple phosphates. It is formed as ammonia increases in 
the urine. Microscopically it is a beautiful sight, the spheres often 
presenting the so-called " morning star" shape or " thorn-apple" crys- 
tals. These are spheres of a dark color, often concentric or radially 
striated, and have on their surface thorns. More often these spheres 
have long projections, giving them very bizarre shapes. They are 
soluble in acetic acid with the subsequent precipitation of uric acid, 
giving off ammonia. 




^ - w W 

Fig. 32. — Various forms of ammonium biurate crystals. V 400. 

The yellow color of these urate sediments is due to urochrome 
especially, also urobilin. The red is due to uroerythrin. This sedi- 
ment may contain all the bile that there is in the urine and much of 
the black pigment in case of carbolic acid poisoning. 

Crystals of sodium biurate are rare, and occur in urines under- 
going ammoniacal decomposition but yet amphoteric. These crystals 
resemble calcium phosphate, but are soluble in acetic acid, which gives 
at once a cloud of uric acid crystals. 

IJric Acid. — Uric acid (see Fig. 34) when pure crystallizes usually 
in rhombs, but in the urine the corners are dissolved, giving the so- 
called " whetstone " crystals. When seen on the edge these crystals 
are very narrow rectangles. They may be single or in rosettes, or 
clustered in the shape of a barrel (see Fig. 34, a, b, 1). Their color is 
from a yellow, to a brown, or they may be colorless. The colorless 
crystals are sometimes perfect hexagons (see Fig. 42, e), in which case 



250 



CLINICAL DIAGNOSIS 



their recognition is difficult, since they resemble cystin perfectly. A 
recent case of Dr. Futcher's, the urine of which he kindly gave me for 
demonstration, illustrates this point. The patient was a girl six years 
of age, with diabetes mellitus. The urine was iooo to 2000 cc. in 
amount, specific gravity about 1035, and sugar 5.1 to 5.5 per cent.; 
nothing of interest microscopically. After twenty-four hours on a 
carbohydrate-free diet the urine was turbid, showing a suspension of 
glistening particles (sp. gr. 1026; sugar 0.6 per cent). Microscopi- 
cally, the turbidity was seen to be due to colorless hexagonal crystals 
almost exactly resembling cystin, many single, most in clumps of even 
macroscopic size. It was only after testing, them chemically that they 
were recognized to be uric acid. On this day no typical uric acid 
crystals were seen. The following day there was a mixture of 
hexagonal and whetstone crystals, and later none of the former were 
found. 

Some are in needles arranged in sheaves (see Fig. 34, 4). 

Their color is due to urochrome, not to urobilin, and the red is 
due to uroerythrin plus urochrome. Urobilin, haematoporphyrin, bili- 
rubin, or biliverdin may give the color to the crystals. In cases of 
carbolic acid poisoning these crystals are a dark brown, almost black 
color. These crystals may occur in masses as large as the head of a 
pin, which cling to the glass (see Fig. 34, 2). 

If these crystals are precipitated artificially by acid they are of a 
reddish-brown color due to black decomposition products of uro- 
chrome; they may be stained by indigo-blue or indigb-red. 

Calcium urate crystals are said to sometimes occur with calcium 
oxalate; they are colorless prismatic crystals, insoluble in hot water, 
give the murexid test, and if acid be added uric acid crystals are de- 
posited. They may be produced by treating the urate sediment with 
lime water. 

Detection. — In acid urine the urate sediments may usually be 
recognized from their gross appearance, but particularly from the 
fact that they disappear on wanning and that all are dissolved by acid 
with the subsequent precipitation of uric acid. Uric acid itself 
is not dissolved by heat or acid. Ammonium biurate is soluble in 
acid, and uric acid crystals then appear. The spheres are of charac- 
teristic form. 

Murexid Test. — The crystal or sediment is evaporated in a 
porcelain dish with dilute HN0 3 . To the residue is added weak 
NH4OH. A beautiful purple-red color is obtained. 

The significance of the urate sediment is very slight, since it depends 
chiefly on the concentration and the acidity of the urine. Uric acid, 




Fig. 33. — Sheaves of ammonium urate (?) needles. X 50. 




Fig. 34. — Uric acid crystals. (The lettered forms are drawn from nature, the figures copied from 

Rieder's Atlas.) 



THE tfKINE : SEDIMENTS 



251 



however, is somewhat more important since it may form large con- 
cretions. 

Phosphates and Carbonates. — (i) AMORPHOUS EARTHY PHOS- 
PHATES and carbonates may be precipitated in any urine by the 
addition of a little fixed alkali. A somewhat similar precipitate forms 
when a weakly acid or. alkaline urine is heated, since the acid salts are 
changed to insoluble basic salts. Both are soluble in acetic acid, the 
carbonates with gas evolution. They are the chief constituent of the 
sediment of an alkaline urine, and may cloud even the fresh urine of 
cases of hypersecretion who lose much acid from the stomach, from 
vomiting or lavage, or diarrhoea. In the so-called phosphaturia, 
however, the total amount of phosphoric, acid is not increased. Micro- 
scopically, this precipitate appears as very coarse colorless granules 
varying considerably in size, which- disappear on the addition of a 
little acetic acid. By the gas formed it may be seen which granules 
were carbonates. 




Fig. 35.— Various forms of triple phosphate crystals. X 400. To the left are coffin-lid shapes ; in the 
lower centre a perfect pryamid ; that in the upper left corner resembles neutral magnesium phosphate ; 
that in the upper right is a partially dissolved crystal. 

(2) Triple Phosphates, MgNH 4 P0 4 6H 2 0. — These beautiful 
crystals (see Fig. 35) appear in urine even still acid as soon as suffi- 
cient ammonia is present to form them. They accompany usually the 
amorphous carbonates and phosphates, and often ammonium urate, 
and may be the chief constituent of the sediment. They belong to the 
rhombic system, and vary in size from those very small to some even 
9 mm. in length. Of their shapes, the so-called coffin-lid crystals are 
characteristic ( see Fig. 35). They are often very irregular and of a 
great variety of shapes, due to rapid crystallization from a concen- 
trated solution, or especially as they become partially dissolved, leaving 
X-forms. Some are said to resemble calcium oxalate crystals, but we 
doubt this, since even when perfect pyramids with square base the 
difference is apparent (see Fig. 35). 

Fern-shaped crystals occur especially in sediments artificially pre- 
cipitated. 



252 



CLINICAL DIAGNOSIS 



In some urines these crystals are nearly all of unusual shapes, — 
very thin plates (see Fig. 35), some with bevelled edges, some appar- 
ently not ; some with square, others with rounded or bevelled corners ; 
some are wedges (see Fig. 36), some triangular prisms; yet all give 
by refraction a greenish hue which is not seen in the calcium oxalate. 

Neutral Magnesium Phosphate, Mg 3 (P0 4 ) 2 22H 2 0. — These 
very rare crystals (see Fig. 42, b) occur in alkaline urines in which not 
sufficient ammonia is present to form the above. Such is the case in 
certain cases of dilated stomach with considerable vomiting, and also 
after the ingestion of magnesium carbonate, etc. These crystals are 
exceedingly refractile, long rhombic tablets with bevelled edges. They 
form a beautiful sediment. Some resemble the very thin coffin-lid 
triple phosphate crystals (see Fig. 35). 

Dicalcium Phosphate. — These crystals form in amphoteric or 
weakly acid urine. They are rare. They appear as small prisms or 




Fig. 36— Atypical forms of triple phos- Fig. 37.— Wedges of dicalcium phosphate, 

phate crystals. X 400. 

wedges in irregular clumps (see Fig. 37), or are massed together in ro- 
settes (see Fig. 42, d) or fan-shaped clusters. These masses or rosettes 
are usually so thick that the individual small crystal can hardly be made 
out. A rather unusual form of probably calcium phosphate is shown 
in Fig. 38. They occur when the urine is rich in calcium and only 
weakly acid; among diseases, especially in joint troubles. They are 
soluble in acetic acid. They may be separated from triple phosphates, 
since 20 per cent, ammonium carbonate will dissolve these and not the 
latter. An unusual calcium phosphate sediment is pictured in Fig. 33. 

Calcium Carbonate. — These crystals (see Fig. 39) may be min- 
gled with the amorphous carbonates in an alkaline urine. They occur 
as amorphous masses or as dumb-bells a little like CaOx, or large con- 
centric radiating spheres. They are soluble in acetic acid with gas 
formation. 



THE URINE: SEDIMENTS 



253 



Neutral calcium phosphate also forms a scum on the surface 
of the urine, even when quite fresh, giving the appearance of a film of 
oil, and which may be easily skimmed off. This consists of an amor- 
phous precipitate which under the microscope resembles sheets, often 
seen when one is not careful always to wipe off the outside of a pipette 
before making a preparation for microscopic examination. 

Oxaluria. — This symptom complex, formerly so respected, has 
fallen into disrepute. The old criterion for its presence w r as a large 
sediment of CaOx crystals, but this sedimentation does not depend so 
much on the total amount of oxalic acid present as it does on its 
solubility. Yet it is of much practical importance, since CaOx occurs 
so often in calculi, in even 30 to 50 per cent, of them, and these are 
the worst stones. The chief source of the CaOx is the food, cer- 
tain vegetables, as beans, artichokes, beets, potatoes, and especially to- 



Fig. 38. — Calcium phosphate (?). X 400. 

matoes, spinach, rhubarb, certain fruits and grains, cocoa, tea, coffee 
being particularly rich. The most ingested is destroyed in the intes- 
tine, only 1 5 per cent, of the oxalic acid being absorbed ; this is dis- 
solved by the HC1 in the stomach and excreted quantitatively as 
CaOx; about 10 per cent, is in the stools, the rest is destroyed by the 
intestinal bacteria and ferments. 148 

To reduce the output, meats, fats, grains, rice, apples, pears may be 
allowed. These contain less calcium, the important point in prevent- 
ing this precipitation. In health the output is about 20 mg. per day, 
with an upper limit of 35 mg. Although the most comes from the 
food, yet a certain amount is from tissue combustion, since some is 
present even in the urine of a starving person. Many consider oxalic 
acid a normal decomposition product of uric acid ; others that glyco- 
coll and creatin are the oxalate formers. Some may be reabsorbed 
from the bile. Bakhoven thinks that of the foods the carbohydrates are 
148 Klemperer and Tritschler, Berl. klin. Wochenschr., 1901, p. 1289. 



254 



CLINICAL DIAGNOSiS 



the chief builders. It bears no relation to the uric acid excretion ; the 
latter, for instance, can be increased by the nucleins, which do not affect 
the oxalic acid output. 

Among the diseases claimed to be accompanied by oxaluria are pul- 
monary tuberculosis, peritoneal tuberculosis, pernicious anaemia, leu- 
kaemia, in which condition the output is claimed to be 33.2 to 53 mg. 
per day, jaundice, diabetes mellitus, gout, diseases of the digestive 
and respiratory organs, cirrhosis of the liver, and especially neuras- 
thenia. It bears some relation to the absence of HC1 in the gastric 
juice and to fermentation processes in the intestine. In diabetes melli- 
tus a large output is quite surely present. This increases as the sugar 
diminishes (vicarious oxaluria). Naunyn mentions three cases with 
quantitative estimations, one with 0.8 gm., the second 1.2 gms. in 
twenty-four hours, the third with 0.5 gm. per litre. In the case of 
neurotic persons an increased output is generally granted, and v. 



Fig. 39. — Calcium carbonate. Fig. 40. — Various forms of calcium oxa- Fig. 41.— A rare form of cal- 
X 400. late crystals and spheres. X 400. cium oxalate crystals. 

Jaksch considers it an independent disease, since it may be the only 
abnormality found. The symptoms in such cases are those of neuras- 
thenia and dyspepsia. It is of interest that insurance companies now 
regard " oxaluria" as an early sign of nephritis. 

Calcium oxalate crystals may precipitate in any urine. The 
cause is not fully known, but their increased presence it is hard to 
associate with any pathological condition. This precipitation is most 
important clinically. The real question is, Why is any in solution? 
Klemperer and Tritschler 149 consider all the acid phosphates aid in 
holding it in solution, the salts of sodium least, calcium more, mag- 
nesium most, and something depends on the absolute amount of CaOx. 
The crystals occur in two forms : 

(i) The octahedral, which belong to the tetragonal system (see 
Fig. 40). These resemble double envelopes or prisms, and may be 
recognized from their appearance (CaC 2 0 4 3H 2 0) . 

149 Zeitschr. f. klin. Med., 1902, vol. xliv. p. 337. 



THE UKINE: SEDIMENTS 



255 



(2) Spheroidal forms (see Fig. 40) which are flat, oval, or nearly 
semicircular with a central groove; hence they resemble an hour- 
glass. They often present a radial striation (CaC 2 0 4 H 2 0). 

A rare form of crystal is represented in Fig. 41, flat plates with par- 
allel sides and rounded ends, which look like superimposed sheets of 
mica, In a recent case the urine had a great many of these. 

These crystals are usually colorless, but may be bile-stained. They 
are transparent and very refractive. They are insoluble in water, very 
little if any in acetic acid, but easily in any mineral acid. Their crys- 
tallization probably depends on the amount of oxalic acid, on the 
relative amount of NaH 2 P0 4 which has a greater ability in holding 
CaOx in solution in a warm than in a cold urine, and especially in in- 
verse proportion to the amount of magnesium. As the precipitate 
forms very slowly, perfect crystals form. They may be found in acid, 
amphoteric, or weakly alkaline urine, and are sometimes present in 
the specimen when voided. 

They attracted considerable attention among the older pathologists, 
as they were supposed to cause an irritation which explained many of 
the symptoms and vicious habits of neurotic individuals. The shape of 
the octahedral forms is quite characteristic, and these cannot well be 
mistaken. Apart from their shape, their refractivity is very suggestive, 
and it is only on hasty examination that they could be mistaken for 
triple phosphate crystals, even when the latter are square and perfect, 
but single, pyramids. They may also be easily separated from these 
by their insolubility in acetic acid. The spherical forms could be mis- 
taken for CaC0 3 , but these are soluble in acid with gas production and 
show a different structure. 

Quantitative Determination of Oxalic Acid. — The Neumann's method is as 
follows : The twenty-four hours' amount of urine is precipitated with calcium 
chloride and ammonia, and then acetic acid is added until a weak acid reaction. 
A small amount of alcohol thymol solution is then added to inhibit bacterial growth. 
The precipitate after long standing, over twenty-four hours in a warm place, is 
washed several times by decantation, pouring the fluid through the filter, then the 
precipitate brought onto the paper. Wash as much as possible by decantation, 
since the fine precipitate easily passes through the paper. The precipitate is then 
dissolved in somewhat warmed dilute HC1, and the paper washed with water 
until the acid reaction disappears. The filtrate is evaporated in a porcelain 
dish on the water-bath to a small volume. The fluid is then placed in a small 
stout cylinder, the dish being washed with water and dilute HC1, and the wash- 
water added to the fluid. Ammonia is then added in excess and the whole stained 
with a few drops of litmus, to be sure of the reaction. After long standing, at least 
twenty-four hours, the precipitate is brought onto an ashless filter paper. It is 
necessary to remove the crystals from the walls of the cylinder by rubbing well 
with a glass rod protected with a small piece of rubber tubing. The precipitate is 
then washed with water until it is chlorine-free, and then with acetic acid. The 
filter is then dried, burned in a platinum crucible at a dull red, then heated with a 
blast flame until at constant weight. Calcium oxalate is thus transformed to cal- 
cium oxide, 50 parts of which correspond to 90 parts of oxalic acid. 



256 



CLINICAL DIAGNOSIS 



Calcium Sulphate, CaS0 4 2H 2 0. — This is a very rare sediment 
occurring in very acid urines. The crystals (see Fig. 42, a) are long 
and thin tablets or needles, single, but more often in clusters, which are 
insoluble in NH 4 OH, alcohol, and acetic acid. They are difficultly 
soluble in HC1, HN0 3 , and hot water. They are more soluble in hot 
water than in cold. The solution should be tested with BaCl 2 , to 
make sure of sulphuric acid. 

Hippuric Acid. — This acid occurs rarely as a sediment, as milk-white, semi- 
transparent, four-sided prisms and rods with ends of two to four planes (see Fig. 
42, c). These are distinguished from uric acid, which they may resemble in form, 
by their greater solubility in water, especially in warm, their solubility in alcohol and 
ether, and that they do not give the murexid test. The normal amount of hippuric 
acid in the urine is from 0.1 to 1 gm. per day, and varies as the diet. 











■ 
























n 

\ ) ' 














c 


i 


d 


e 









Fig. 42. — Various crystals, a, calcium sulphate ; b. neutral magnesium phosphate ; c, hippuric acid ; 
d, acid calcium phosphate ; e, colorless uric acid. (Copied from Rieder's Atlas.) 

Hetero-albumose. — In two cases it has been found in the sediment, once crys- 
talline and once amorphous. 

Xanthin. — Two or three cases have been reported in which xanthin crystals 
appeared in the sediment. These resembled uric acid somewhat (see Fig. 43, d), but 
are soluble on heating and in ammonia. They are evaporated in quite concentrated 
HNOs on a bath, and give a yellow residue. On careful heating further over a 
small flame this becomes intensely yellow, and if KOH be added, yellowish-red. 
Warmed further, it becomes a deeper red, even a violet-red. This is not the 
murexid test, and should not be confused with it. 

Haematoidin (Bilirubin). — These crystals appear as needles (Fig. 
43, a) or rhombs (b) in the sediment, sometimes in hemorrhagic 
nephritis, and in very jaundiced urine especially after acid is added, 
in acute yellow atrophy and in fragments from cancers. They 
also occur in pyonephrosis and after transfusion. In the jaundice of 
the newborn they occur in the epithelial cells of the urine. They have 
also been found in waxy kidney, scarlet fever, typhoid fever, and car- 
cinoma of the liver with jaundice. They also occur in amorphous form. 



THE URINE: SEDIMENTS 



257 



Indigo. — The crystals of indigo may occur in normal decomposing urine as 
a scum of blue needles arranged in stars, or blue rhombic plates, soluble in chloro- 
form to blue solution. These are more often seen in the decomposing urine of 
peritonitis, pyelonephritis, etc. One also sees violet-red bundles of crystals or 
plates of indigo-red. 

Melanin has been found rarely as amorphous scales, 

Haemoglobin occurs in cases of hsemoglobinuria as amorphous scales, plates, 
or casts. 

Cholesterin. — Cholesterin sometimes occurs in flat superimposed 
plates, often with re-entrant angles (see p. 672), in such amounts as 
to justify the term " cholesterinuria." It is always found in associ- 
ation with other fats. This may occur in vesical catarrh, especially in 
pyelitis, pyonephrosis, echinococcus cysts of the kidney, and nephritis. 
The crystals are also formed from the fatty degeneration of pus-cells 
and of breaking-down tissue. It is rare from fatty degeneration of 
the kidneys, and does not occur in chyluria, in which case one would 



Fig. 43. — Various crystals of the urine, a, haematoidin needles ; b, haematoidin crystals ; c, leucin ; 
d, xanthin ; e, tyrosin. (Copied from various authors.) 

expect it. Hirschlaff 150 reports a case of hydronephrosis (thought to 
be due to a stone and with the emptying of a large sack) with even 
5.8 gms. of cholesterin in 100 cc. of urine. We had a case of long 
standing cholesterinuria of considerable degree in a case of renal cyst 
of doubtful nature. 

Cholesterin is insoluble in cold alcohol, but easily in hot, reprecipitating on 
cooling, and is soluble in chloroform. If the cholesterin solution be superimposed 
on concentrated H2SO4, the former solution is first blood-red, then more violet-red, 
while the sulphuric acid becomes dark red with green fluorescence (Salkowski). 
If the crystals microscopically be brought into contact with H2SO4 4 parts, H 2 0 
1 part, this play of colors can be watched. 

Leucin and Tyrosin. — Leucin and tyrosin occur in the urine in cer- 
tain pathological conditions. As a spontaneous sediment leucin does 
not occur, while tyrosin has been found in very few (three) cases, one 




150 



Deutsches Arch. f. klin. Med., 1899, vol. lxii. p. 531. 



17 



258 



CLINICAL DIAGNOSIS 



of which was of acute yellow atrophy, one of phosphorus poisoning. 
These bodies may often be found in solution in acute yellow atrophy, 
phosphorus poisoning, rarely in smallpox, severe typhoid fever, per- 
nicious anaemia and leukaemia. With the exception of the few cases 
in which the tyrosin sheaves have been found in the unconcentrated 
urine, it is necessary to evaporate the urine to about one-tenth its 
volume. The addition, then, of alcohol will usually give a sedimenta- 
tion of needles of tyrosin and spheres of leucin ; peptone and lactic 
acid are also present. The needles of tyrosin are black in appearance 
and are grouped together like sheaves of wheat (see Fig. 43, e). Since 
jaundice also occurs in practically all cases, the crystals of bilirubin 
must be excluded ; these have an intense brown color, but in some cases 
a rather similar shape. In an alkaline urine the calcium phosphate 
must be excluded. Leucin, if pure, is in groups of spherules (see Fig. 
43, c) which have little refractility and hence differ from the urates. 
They have a much clearer contour and no spicules, and a hyaline or a 
radiating structure. Their appearance varies, however, with their 
purity, and if impure they may be in spheres or masses with no 
hyaline structure whatever. They may have a dark centre and a clear 
periphery, or vice versa. 

The microscopical diagnosis of these bodies is almost never suffi- 
cient, but should be confirmed by chemical tests. In so doing it is 
quite necessary to use a fresh urine, since these bodies rapidly and 
easily form in a decomposing albuminous urine, hence in an old urine 
the question is whether they are preformed or not. 

In all tests it is necessary, first, to remove the albumin by heat and 
acid and examine the filtrate. This is first precipitated with neutral, 
then with basic, lead acetate until all precipitation ceases. The urine 
is then filtered, the lead removed with H 2 S, the filtrate concentrated 
by evaporation. The tyrosin even now separates out slowly if in con- 
siderable amount. The concentration should be carried on to very 
small volume, and the urea extracted by absolute alcohol. The resi- 
due is then boiled with weak ammoniacal alcohol and the filtrate is 
again evaporated to small volume and then allowed to crystallize. 
The leucin or the tyrosin will separate out, that one first which first 
becomes saturated. The partial separation may be obtained with alco- 
hol in small volume which dissolves the leucin more easily than the 
tyrosin. If no precipitate appears, again dilute and precipitate with 
basic lead acetate and repeat. 

A better separation of leucin and tyrosin is the following. The residue after 
evaporation is dissolved in boiling water plus a little ammonia. To the hot solu- 
tion is added basic lead acetate, stirring all the while until the precipitate is no 
longer brown but white. It is then filtered, heated nearly to boiling, made slightly 
acid with dilute H 2 S0 4 , and then boiled to drive off the ammonia and to pre- 



THE UEINE: SEDIMENTS 



259 



cipitate the lead. It is then rapidly filtered and cooled. The tyrosin will precipitate 
almost quantitatively. To the solution is added HLS to precipitate the lead, and 
it is evaporated to smaller volume. While boiling Cu(OH) 2 freshly precipitated 
is added in excess and the boiling continued for a few minutes. The precipitate 
will contain part of the leucin. This precipitate is suspended in boiling water, 
decomposed with H 2 S, and a little acetic acid added. It is then filtered. The 
filtrate is decolorized with animal charcoal and evaporated to small volume. On 
cooling the leucin will separate out. The rest of this body will be in the blue 
copper compound. It is very hard to get leucin pure, although it can be done by 
forming its ethyl ester. 

Tyrosin, C 6 H 4 CH 2 CHNH 2 COOH.— Tyrosin crystals (see Fig. 
43, e) precipitate from water solutions in bundles of needles arranged 
like sheaves of wheat, from ammoniacal alcohol in bunches of prisms. 
These are soluble in water, slightly in alcohol, not at all in ether, and 
easily in acids and alkalies. Its crystalline shapes are not characteris- 
tic. The sediment should be filtered out, washed with water, dis- 
solved with ammonia plus a little ammonium carbonate in warm solu- 
tion, and evaporated until it recrystallizes. The chemical tests cannot 
be made directly in the urine. 

Piria's Test. — Some dry tyrosin is placed in a test-tube and a few 
drops of concentrated H 2 S0 4 added. This is warmed gently and then 
boiled in a water-bath for half an hour. A red solution of tyrosin 
sulphate is obtained. The solution is cooled. To it should be added 
several volumes of water. This fluid is then neutralized with BaC0 3 , 
and filtered. The filtrate is evaporated to a few cubic centimetres, 
and weak Fe 2 Cl 6 is then added (acid-free) to the cooled solution. 
A fine violet color results. This test is prevented by free mineral 
acids or an excess of Fe 2 Cl 6 . 

The hot aqueous solution of tyrosin gives, with Millon's reagent, 
(Hg(N0 3 ) 2 +KN0 2 ), while hot a fine red color, and an abundant 
red precipitate. 

Leucin (CH 3 ) 2 CHCH 2 CHNH 2 COOH.— Leucin is present as 
spherules; their color and regularity of outline depend on the purity 
of the specimen. Often daughter spherules project from them, and 
they frequently show a striation. Leucin (see Fig. 43, c) is soluble in 
water, less in alcohol, and very in acids and alkalies. All of these com- 
pounds are more soluble in an impure than in a pure condition. None 
should ever be expected in a sediment until the urine is concentrated. 
It is isolated by the above methods. For the chemical tests it must first 
be purified by recrystallizing from hot ammoniacal alcohol. The char- 
acteristic tests are its crystallized form when pure, the fact that it sub- 
limes at a gentle heat at 170 0 C. without fusion to a woolly mass and 
with the odor of amylamine. 

Scherer's Test. — Pure leucin plus a little HN0 3 is evaporated 
on a platinum foil. A colored residue is obtained. The slight residue 
is warmed with NaOH, and a water-clear, if pure, or colored if im- 



260 



CLINICAL DIAGNOSIS 



pure, fluid results. This is evaporated carefully and an oily fluid ob- 
tained which rolls around without wetting the foil. This test is char- 
acteristic for even impure leucin. 

Salkowski's Test. — To the specimen is added a little water plus 
one or two drops of 10 per cent. CuS0 4 . A blue solution is obtained, 
(C 6 H 12 N0 2 ) 2 Cu, which does not reduce on heating. 

Cystin. — This rare condition (only 131 cases now reported in lit- 
erature. Simon and Campbell), which occurs in certain persons per- 
haps during their whole life, is accompanied by no symptoms except 
those from the calculi formed ; some persons undergo repeated opera- 
tions because of these stones, and live a life of misery. The formation 
of calculi, however, is intermittent, and after a period of misery the 




Fig. 44. — Cystin crystals from urine. X 400. 

person may for a long time be free. The output of cystin is in some 
cases intermittent. 

Cystin is a normal intermediate product of normal proteid metabolism, the 
sulphur portion of the proteid being for the most part, possibly all, in this radical. 
It is not normal in the urine ; if fed to a normal person, about 66 per cent, of its sul- 
phur is excreted as sulphates and about one-third as neutral sulphur ; none as cys- 
tin. Simon and Campbell 151 think some is eliminated in the bile as taurocholic acid. 
Why it should be excreted is not known. There are two general theories, — the 
one that it is the product of an intestinal mycosis, which is borne out by the fact 
that both intestinal contents and urine contain certain diamines, as cadaverin, 
putrescin, and others ; the other, that it is an individual variation in metabolism, 
an inability on the part of the organism to oxidize the cystin nucleus. 

In the urine while fresh are seen hexagonal transparent crystals of 
cystin. These crystals (see Fig. 44) are very characteristic, yet not 
absolutely so, since in certain cases the uric acid may assume this 
form. Sometimes large concretions form, from a pin-head size to 
1 cm. in diameter, which are rather soft and waxy, crystalline on cross- 
section, and are of a whitish-yellow color. These crystals are soluble 
in ammonia and reprecipitated by acetic acid, a test which must be 
applied to exclude uric acid. 

151 Johns Hopkins Hosp. Bull., 1904. 



THE HEINE: SEDIMENTS 



261 



We have seen but four cases. One of these patients has on many 
occasions for some years had these stones crushed. Another case, a 
woman, was distressed for years by these concretions, but refused 
operation, and as she has since then attained considerable success in 
public life, we presume that the stones no longer bother her so much. 

The urine in such cases on standing often gives the odor of H 2 S. 
It is in this condition particularly that the neutral sulphur of the urine 
is largely increased, and the neutral sulphur is the best index of the 
amount of cystin present. 

The presence of diamines in the urine and in the faeces in traces 
has attracted some attention. 152 

There occurs sometimes putrescin, sometimes cadaverin, sometimes 
both, and their presence is variable and intermittent. Lewis and Si- 
mon, in 1902, stated that they had been found in seven cases. 

Baumann's method for their detection is as follows : The twenty-four hour 
amount of urine is shaken up with 10 per cent. NaOH and benzoylchloride (in the 
proportion of 1500:200:25) until the odor of benzoylchloride is gone. 

The precipitate (of phosphates, carbohydrates, and benzoylated diamines) is 
filtered with the aid of a suction-pump. The precipitate is digested with alcohol, 
filtered, the extract evaporated to small volume, 30 volumes of water added, and 
allowed to stand twelve to forty-eight hours. The benzoylated diamines separate 
out in the milky fluid as a voluminous sediment of white crystals. This is 
redissolved in alcohol, concentrated to small volume, and diluted again with water. 
This is repeated several times to separate the carbohydrates. 

From the first filtrate more may be recovered by acidifying with H2SO4 and 
extracting three times with ether. To the ether residue is added 12 per cent. 
NaOH till neutral, then 3 to 4 volumes of the alkali. This is then kept in a cold 
place for crystallization and crystals of cystin and the diamines will separate. 
They are filtered and suspended in cold water ; the benzoylchloride crystals remain. 

The crystals are dissolved in a little warm alcohol, then 20 volumes of ether 
added ; benzoylputrescin is precipitated, melting point 175 0 to 176 0 C. The ether 
residue contains benzoylcadaverin, melting point 129 0 to 130 0 C. 

Unorganized Sediments. — The following outline for use in recog- 
nizing an unorganized sediment is so useful that we quote it in full as 
given by Neubauer and Vogel. 
A. Acid urine. 

(a) Sediment amorphous. 

(1) Sediment consists of fine granules in clumps, mingled with 
which are crystals of uric acid and calcium oxalate; urate sediment. 
This sediment is soluble on warming, and if a drop of strong acetic 
acid be added the granules gradually disappear with the subsequent 
separation in a few hours of uric acid crystals. 

(2) Dumb-bell shaped bodies. 

(a') Insoluble in strong acetic acid, soluble in concentrated 
hydrochloric acid without subsequent crystallization ; calcium oxalate. 

152 Simon, Am. Jour. Med. Sci., 1900, vol. cxix. p. 39; 1902, vol. cxxiii. p. 838; 
Schollberg and Garrod, Lancet, August 24, 1901. 



262 



CLINICAL DIAGNOSIS 



(¥) Insoluble in concentrated hydrochloric acid; probably 
calcium sulphate. The sediment should be filtered, washed, dissolved 
in much hot water, and tested for calcium and sulphuric acid. 

(3) Very refractive globules, soluble in ether; fat. 

(4) Amorphous yellow granular masses: bilirubin or hcematoidin. 
(b) Sediment crystalline. 

( 1 ) Yellow or brown whetstone-shaped crystals, single or ro- 
settes, alone or with amorphous urates and calcium oxalate : uric acid. 
These crystals are soluble in sodium hydroxide, then with the 
addition of concentrated hydrochloric acid a reprecipitation of uric 
acid crystals. 

(2) Small yellow rhombic tablets alone or with amorphous gran- 
ular tablets of the same color, often embedded in tissue detritus : bili- 
rubin or hcematoidin. 

(3) Colorless (or yellow in a decomposed urine), transparent, 
strongly refractive octahedrons, or double envelope forms, or quad- 
rangular short and narrow prisms with octahedrons at the ends, in- 
soluble in acetic acid, soluble in hydrochloric acid: calcium oxalate. 

(4) Crystals somewhat similar to the last mentioned, or large 
coffin-lid crystals, soluble in acetic acid : ammonium magnesium phos- 
phate {triple phosphates). 

(5) Symmetrical hexagonal tablets, sides and angle almost equal, 
insoluble in acetic acid, soluble in ammonia : cystin. 

(6) Colorless whetstone-shaped tablets, insoluble in acetic acid; 
soluble in ammonia. On the addition of hydrochloric acid to this 
solution hexagonal tablets separate: xanthin. 

(7) Large, flat, strongly refractive elongated rhombic tablets, 
soluble in acetic acid, and partially in ammonium carbonate : normal 
magnesium phosphate. 

(8) Prisms, single or in rosettes, 

(a') Soluble in ammonia: hippuric acid. 

(b') Insoluble in ammonia and in acids: calcium sulphate. 

(9) Wedge-shaped prisms, single or in clusters, or in thick rosettes, 
which are decomposed by ammonium carbonate, and soluble in acetic 
acid: acid calcium phosphate. 

(10) Bunches of very fine needles insoluble in acetic acid, soluble 
in ammonia and hydrochloric acid : tyrosin. 

B. The urine alkaline when the crystal precipitates. (After the 
urine becomes alkaline many of the sediments previously mentioned 
which separate in the acid urine may still remain. ) 

Amorphous. 

( 1 ) Small granules together with triple phosphate crystals, 

(a') Soluble in acetic acid without gas formation: normal 
phosphates of the alkaline earths. 



THE URINE: SEDIMENTS 



263 



(b') Soluble, but with gas formation: carbonates of the alka- 
line earths. 

(2) Dumb-bell shaped masses or large spheres, soluble in acetic 
acid with gas formation : calcium carbonate. 

(3) Large dark spheres often covered by small projecting crystals : 
ammonium urate, soluble in hydrochloric acid or acetic acid with the 
subsequent separation of the rhombic crystals of uric acid. 

Crystalline. 

( 1 ) Large colorless prisms, many coffin-lid shaped : triple phos- 
phates, soluble easily in acetic acid. 

(2) Rosettes of very fine blue needles or blue tablets : indigo. 

( 3 ) Rosettes of violet-red needles or rhombic platelets : indigo- 
red. 

Chyluria. — Chyluria differs from lipuria in its gross characteristics, 
the term being used of a urine which resembles an emulsion of fat, 
hence like dilute milk. When less fat is present and the gross appear- 
ance not so striking, the term lipuria is used. 

In chyluria considerable fat is present. This may form gross tal- 
low-like masses, but as a rule the particles are microscopically much 
finer than in milk, even on the limits of visibility. The urine appears 
like a thin milk, and sometimes has a reddish tinge of blood, in other • 
cases a whey-like appearance. Fresh, the urine is weakly acid or neu- 
tral, and does not have the normal urinary odor. On standing often 
a cream arises or a fibrin coagulum forms. In addition to the fat the 
urine contains always albumin, sometimes cholesterin and lecithin. 
The proteids found are serum globulin and albumin. Fibrogenic sub- 
stances have also been found, hemialbumose and peptone. The proteid 
may be present from 0.2 to 2 per cent, or more, and the fat from a 
trace to 3 per cent. A few leucocytes may be present and a few red 
blood-cells. In parasitic chyluria one finds the eggs and embryos of 
Filaria usually in coagula. Casts, etc., are always absent unless a com- 
plicating Bright's disease is present. The urine may be chylous during 
the night, and clear during the day, or vice versa. In other cases the 
excretion of the fat is dependent upon the position of the patient, 
occurring only when he is in a vertical position, after digestion, bodily 
exercise, or excitement. In certain cases the coagula formed in the 
bladder have caused considerable trouble. It is a disease which lasts 
from months to years, often with intermissions. It may cease spon- 
taneously. This disease occurs endemic in the tropical and subtrop- 
ical regions, in some cases in the temperate zone. 

There are two forms, that due to the filaria, and the non-parasitic 
form the etiology of which is not understood. 

Concerning the latter, some say that sugar is not present in the 
urine, and were it simply lymph present it certainly would be; also 



264 



CLINICAL DIAGNOSIS 



that there is a higher percentage of fat in the urine than occurs in the 
ivmph. Again, there is no decrease in the percentage of the normal 
urine constituents. In some cases a fat diet will increase the chy- 
luria, and even a foreign fat may be recognized. The theory of 
Claude Bernhard was that chyluria was the result of an abnormal fat 
content of the blood due to poor assimilation; but an increase of the 
fat of the blood is very rare, and this does not explain the albumin 
found in the urine. Others think it due to liver disease. All that can 
be said is that there is no severe renal lesion which explains it. Franz 
and Styskal think that the fat escapes from the lymphatic vessels since 
the chyluria diminishes or disappears if the patient be fed a fat-free 
diet or starved ; since foreign fats of the food can be recognized in the 
urine; and, finally, since the cells of this exudate are lymphocytes. 

Lipuria. — As has been said above, this differs from chyluria in its 
gross appearance. It is a condition which is often reported in the hos- 
pitals, but by beginners who have not excluded oil in the catheterized 
specimens of urine. Again, the microscopical appearance is not always 
sufficient. It should be tested chemically, the urine extracted with 
ether, and the residue examined. This heated gives the odor of acro- 
lein. The residue also will make a fat-spot on paper, and will give the 
osmic acid test. 

Also to be excluded are, fat from the rectum, deception, the tena- 
cious phosphate sediment, and the scum of bacteria forming at the 
top of the urine. Normally there is microscopically little if any fat in 
the urine, and of this the source is the blood. Lipuria may result from 
an over-ingestion of fat in the diet or as a medicine (cod-liver oil), the 
so-called " alimentary lipuria ;" from the subcutaneous injection of oil 
or oil rubbed into the skin; the fat may come from various organs, 
especially after fractures of bones if the marrow be crushed ; rarely 
after inflammation of the marrow ; in eclampsia, which disease was 
formerly supposed to be due to the crushing of the fat of the pelvis of 
the kidney ; crushing or tearing of the subcutaneous fat, of the liver, 
or of fatty tumors ; among diseases are, diabetes mellitus, alcoholism, 
tuberculosis, adiposity, nephritis, certain mental diseases, pancreatic 
diseases, cardiac diseases ; after various protoplasmic poisons. In the 
last mentioned group there may be an increase of fat in the blood, but 
this needs confirmation. The relation of the lipuria to lipaemia has been 
proved for fractured bones, subcutaneous bruises, and diabetes mellitus. 
In the diseases of the urinary organs a slight grade of fatty degenera- 
tion of the kidneys may explain the condition, which occurs in nephritis, 
various infections, intoxications, anaemias, and cachexias. The fat may 
also arise from the fatty degeneration of epithelial cells, leucocytes, 
casts, and fragments of tumors ; in such cases the most of the fat 
remains in the cells, or collects in droplets which float on the surface. 



THE UEINE: SEDIMENTS 



265 



Organized Sediments. Mucous Sediment. — The " nubecula" is a 
very faint cloud of mucous strands appearing soon after the urine cools, 
which first collects at the top, then sinks to the bottom of the glass. 
It is mucus from the epithelial cells of the urinary passages. These 
strands enclose a few " mucous corpuscles," mononuclear or polymor- 
phonuclear leucocytes often some amoeboid, and some crystals. When 
much mucus is present in the urine it may form a translucent or cloudy 
coagulum-like sediment which is more clearly seen after the addition 
of acetic acid. This is the product of desquamatory catarrh of the 
mucosa. 

Epithelial Cells. — It is normal for a few cells to be present in the 
nubecula, since the mucosa of the urinary passages is an epithelial 
surface, hence is always desquamating somewhat. These cells are 
increased in inflammatory and destructive lesions, in which case cells 




Fig. 45. — a, e, d, cells from male urethra ; b, f, cells from transitional epithelium ; c, shadows of 

red blood-cells. X 400. 

from the lower layers, which are normally never present, may also 
appear. 

Renal Epithelial Cells. — The cells from the kidney (see Fig. 
47, e) are round or cubical, a little larger than leucocytes (12 to 25 
microns) from which they are distinguished by their size and nucleus. 
The latter is large and vesicular, especially well seen if stained. The 
protoplasm is nearly always fatty, either finely so, or so very fatty that 
it may resemble a colostrum corpuscle (c, h). These cells some- 
times show definite myelin degeneration and free myelin globules 
similar to those in the sputum (see Fig. 47, d). 

These are very rare in normal urine, occur in any form of ne- 
phritis, but especially the acute parenchymatous, singly, in clumps, or 
attached to casts, and in renal infection in masses of pus-cells (see 
Fig- 47)- 

Epithelial Cells from the Urinary Passages (see Fig. 46, 
b, c, d, and Fig. 45, b, f). — These cells may be large and irregular, 



266 



CLINICAL DIAGNOSIS 



round or polygonal; they are flat, with clear protoplasm and 
usually with a small, very distinct central nucleus. Their edges 
are sometimes very refractive, thin, and horny. These are the typical 
pavement cells from the superficial layers of transitional epithelium. 
In cases in which they are largely increased, as, for instance, the result 
of too strong irrigating fluids, they may occur in large sheets. Daw- 
son 153 found that these cells varied in size and shape, some being 
irregular, large, and polygonal, some smaller and hexagonal, the 
larger often having a peripheral non-granular zone. The nucleus was 
round or oval, sharply defined and central, and many were budding. 




Fig. 46. — Various forms of epithelium cells in the urine, a, "tailed" cells; b, d, small polygonal; 
c, large surface cells ; to the right of d is a small round cell of uncertain origin ; e, squamous cells 
from vagina. All of these cells except e were obtained by ureteral catheterization, hence from the 
pelvis of the kidney or scraped from the mucosa of the ureter. The latter is especially true of b, c, d, 
and neighboring cells, which are the forms one gets from normal cases, a were from cases of pyelitis. 
X 400. 



Among these cells were large giant-cells with fifteen nuclei. In no cells 
did he see the cupping of the under surface supposed to be present. 

The flat polygonal squamous epithelial cells (see Fig. 46, e) 
from the prepuce, end of the ureter, vagina, and fossa navicularis, can- 
not always be distinguished from the superficial cells from the bladder, 
although usually the stratified grouping of those from the vagina 
makes diagnosis easy. 

The cylindrical cells ( see Fig. 45, a, e, d) of the urethra are 
longer, bluntly pointed, and smaller than the above, and occur in pairs 
or clusters. 

153 Johns Hopkins Hosp. Bull., July, 1898, p. 155. 



THE UKINE: SEDIMENTS 



267 



There are found smaller polygonal or elliptical cells from the other 
layers of the mucosa of the bladder, ureter, and pelvis, which consist 
of a very granular protoplasm and a large nucleus (Fig. 46, a, b, d). 
Other cells are more oval, often irregularly conical, with one or two 
branches. Their nucleus is very distinct, their cell body long and 
thread-like. In addition are small round cells, with round nucleus like 
mononuclear leucocytes (see Figs. 46, 47), which, indeed, they may 
be, or cells from the deep layers of epithelium. We have seen good 
numbers of these round and tailed cells in the urine obtained by ure- 
teral catheterization from normal kidney (always with some blood). 













IP e e 


























d w 
















c . h 


• 1 




■[■':\ : ;^r f 




, 1 




€*P 1 








■ 












0" ffik & 

















Fig. 47. — a, pseudo pus-cast; b, epithelial cast showing protoplasmic bridges between cells; c, two 
very granular (myelin?) renal cells; d, myelin globules; e, renal epithelial cells; f, crenated red blood- 
cells ; g, pus-cells ; h, very fatty renal epithelial cells. X 400. 

These come from the middle or deeper layers of the mucosa, anywhere 
from the pelvis of the kidney to the bladder, singly or in clusters. 

Some suppose that they can recognize the cells from the various 
parts of the urinary passages. Others, and this is our opinion, believe 
that this is usually impossible. Sahli considers that the predominance 
of tailed cells over flat cells indicates a pyelitis. We have seen such 
cases, but in a recent case of intense pyelitis, the urine obtained at 
autopsy from the pelvis of the kidney, the point failed. A former idea 
was that all tailed cells came from the pelvis of the kidney. The 
smaller polygonal cells from the ureter (Fig. 46, b, d) in groups 
are suggestive. These are the cells scraped off by the ureteral catheters. 



268 



CLINICAL DIAGNOSIS 



In a recent case of streptococcus pyelitis the urine from the pelvis of the 
kidney showed great numbers of small round or polygonal and tailed epithelial 
cells in groups of considerable size, scores in each field (of 400 magnification), and 
of the large polygonal cells three to four in each field. Pus-cells were in great 
numbers ; little mucus was seen. 

Casts. — These have been divided into cellular, granular, and amor- 
phous ; the latter show no structure, "but are homogeneous or with a 
faint striation. All combinations and transitions of these casts, and 
casts with various elements fastened to them, occur. 

Epithelial Casts (Figs. 47 and 50). — These are made up of 
renal epithelial cells; in some cases aggregations of desquamated cells 
are massed together; others are certainly desquamated portions 
of the tubules, presenting a lumen, and having the intercellular 
protoplasmic bridges visible (Fig. 47). In one kidney which we 
have had opportunity to study, in sections of the cortex the invaginated 



Fig. 48.— Coarsely and finely granular 

casts. X 400. 




Fig. 49. — Waxy casts. X 400. 



tubules of epithelium could be easily seen, which breaking off would 
give casts. Such perfect fragments are called " epithelial tubes." 
The cells may be well preserved, or present a marked fatty or granular 
degeneration. The nuclei are round and vesicular; for the recogni- 
tion of the cast it is necessary to determine this point. All transitions 
between these and coarsely granular and fatty casts are seen. 

Granular Casts (Fig. 48). — The granules may be coarse or fine. 
The former give to the cast a yellowish-white color. All transitions 
between the epithelial or leucocyte and coarsely granular casts may 
be found. The granules are soluble in acetic acid. To these casts 
may be attached epithelial cells, leucocytes, or red blood-cells. The 
coarsely granular casts probably represent the granular disintegration 



THE UKINE: SEDIMENTS 



209 



of epithelial casts, and are formed either from epithelial tubes or from 
masses of cells which have previously undergone such disintegration; 
the outline of cells can sometimes be seen, and fat globules are com- 
monly also present. This term often includes the haemoglobin casts 
which are of a brownish red color. But another group of finely 
granular casts is somewhat different, and transitions between these 
and the opaque finely granular are not common; that is, not in the 
same case. These casts are covered by very fine granules, are less 
opaque than the coarsely granular, and fat droplets are not commonly 
present. When the cast is only partly finely granular the rest is 
hyaline; in the case of the coarsely granular it is waxy. 

Fatty Casts (Fig. 50). — These striking objects are masses of 
fatty globules, often preserving the outlines of the original epithelial 
cells. They are yellowish or even blackish in appearance, soluble in 




Fig. 50.— To the left an epithelial cast with very fatty cells ; in the centre a fatty cast; to the 
right two leucocyte casts. X 400. 

ether; fatty acid crystals may project from them. If any cell outline 
can be made out, the cast usually is called epithelial. 

Waxy Casts (Fig. 49). — These casts are very refractive, sharply 
contoured, often of a white or yellowish color, homogeneous, and 
show a great tendency to split transversely, hence sometimes are 
in very small pieces. This appearance of great brittleness is quite 
characteristic. They may have any cellular elements attached. They 
are probably a further modification of the granular detritus of epithe- 
lial cells. Their appearance is that of wax. They are broader than 
the hyaline. Some give the amyloid reaction, others do not. They 



270 



CLINICAL DIAGNOSIS 



are not characteristic of the amyloid degeneration, as was formerly 
supposed, and yet in a recent case of amyloid disease practically every 
cast was a waxy cast. In general there are two very distinct forms 
of waxy casts, — the yellow and the blue. The former were often called 
fibrin casts; they resemble beeswax, the latter paraffin. These occur 
in any nephritis with granular casts, especially when the urine is 
diminished, or just before death. 

In the urine obtained just before death one may see the most beautiful waxy 
casts. In one such case recently there were many granular and waxy, no hyaline. 
The casts were enormous, many granular being 0.136 mm., and waxy 0.102 mm. 
in diameter. The latter looked as if cut out of paraffin. But this is not always 
the case. In another specimen only hyaline casts were present, no waxy. But 
these casts were not typical hyalines, yet they were not at all refractive. In other 
cases all forms may be found. The great difference between hyaline and waxy 
casts is their refractility, and it is hard to believe that they are not directly related. 

Between this group and the next is a very large group of casts, 
the commonest form in some cases of nephritis, which have not the 
physical properties of wax, yet are more distinct and solid-looking 
than the hyaline, which name they bear. It is important to recognize 
that some of these have deposited on them fine granules from the 
urine, giving them the appearance of the finely granular casts. Their 
chief difference from waxy casts is that they are not so solid-looking 
and do not give the same color tests. 

Hyaline Casts, Colloid or Glassy Casts (see Fig. 51). — These 
are pale, very little refractive, watery in appearance, and difficult to 
see unless the light is almost shut off, or unless crystals or cells are 
attached to them. It is advised to stain them with Lugol's, giving them 
a yellow color, or aniline-violet, giving blue. They give the micro- 
chemical tests for albumin. They may have the same cells attached 
as the above mentioned casts. Their outline is very regular. These 
casts, which occur in circulatory disturbances where there is no ques- 
tion of inflammation, are so different in appearance from the hyaline 
casts just mentioned that they deserve a separate name. They are 
soluble in acetic acid. 

Blood-Casts (see Fig. 52). — Blood-casts are coagula of red 
blood-cells which have formed within the tubules. The term is also 
applied to any of the above casts with red blood-cells attached. Some 
of the blood-cells are so pale that it is hard to recognize them. 

Hemoglobin. — Casts of haemoglobin are seen in hemoglobinuria, 
the haemoglobin occurring in amorphous masses. Some seem like 
other casts impregnated with haemoglobin. 

Pus-casts (see Fig. 50) are formed in similar way as the blood- 
casts. The nuclei must be seen and their polymorphous nature certain, 
to be sure it is not an epithelial cast. This may be done by adding 



THE HEINE: SEDIMENTS 



271 



acetic acid. Another point to differentiate from epithelial casts is the 
spherical shape of the pus-cells. These casts are rare, yet often other 
casts are seen with leucocytes attached which go under the same 
name. 

Cylindroids (see Fig. 53). — It is common and right to divide 
these into two groups. The first is of the so-called mucous threads, 
which are flat ribbons of mucus which no one would confuse with 
hyaline casts. Their length is considerable, several fields in fact ; they 
vary in diameter, on the whole are narrow, and clearly show their 
ribbon-like nature. Such threads make up the nubecula. In addi- 
tion to these and differing much from them in appearance are seen 
elements which look much like hyaline casts for the most of their 



■1 




Fig. 51.— Hyaline casts of urine. X 400. Fig. 52.— Blood-cast. X 400. 

length, but at one end run off into a longer or shorter thread. Those 
particular on this point exclude from the list of casts anything which 
has one end at all tapering and thread-like. These casts appear to be 
circular on cross-section. They have not the fibrillar nature of mucous 
threads. They occur where casts would be expected, practically 
always with true casts, and have the same significance as they. Of 
one thing we are quite certain, that for the most of their length they 
are typical hyaline casts, and when, as may occur in the centrifuge, 
the thread-end is broken off, the other fragment could not be dis- 
tinguished from a cast. The cylindroids may be covered by urates, and 
hence have the appearance of granular casts. Chemically these are 
like casts. The point is of considerable importance, for if mucous 
threads they certainly arise from the mucous surface, while if casts they 
should arise in the renal parenchyma. They were first described as of 



272 



CLINICAL DIAGNOSIS 



some significance as casts. It is perhaps safest to observe the old rule 
and exclude all from the list of casts which have a definite tail at one 
end. The true mucous threads are insoluble in acetic acid. Their 
origin is the bladder chiefly. One seldom sees them in urine catheter- 
ized from the pelvis of the kidney. 

Combined Casts. — A cast may be waxy or hyaline at one end, 
granular at the other, or may have cellular elements attached. They 
take their name from the latter. 

Bacterial Casts. — Masses of bacteria in the shape of a cast occur 
in purulent infectious pyelonephritis and in pysemic kidneys, but a cast 
also may become permeated by bacteria, either in the body or after 
voiding, in a remarkably short time. 

Urate Casts. — In uric acid infarcts of the kidney of the new- 
born masses of sodium urate may be found in the urine. 



' ; 'a 





Fig. 53. — a, cylindroids, i.e., bodies much resembling hyaline casts; b, mucous threads ; c, a spiral 
structure of material resembling hyaline casts or mucous threads ; d, a vegetable thread. X 400. 

Pseudo-casts of urates are commonly seen. It is not at all un- 
usual for a urate sediment to assume this form. All casts in a con- 
centrated urine may become incrusted with urates, and hence be of a 
dark homogeneous granular nature. True granular casts are not 
homogeneous, are coarser and more refractive than these pseudo- 
casts, which also have uneven edges and disappear on warming. 
Scratches in the glass are sometimes confusing (Fig. 54). In some 
cases of pyuria (cvstitis, e. g.) the pseudo-casts are very perfect (Fig. 

47). 

The length and the breadth of casts vary. Their size may be from very small 
fragments to 1 mm. in length or longer. These very long casts are almost always 
hyaline, and are not mucous threads. Their diameter is narrow or broad. From 



THE UBINE: SEDIMENTS 



273 



the size of the casts no conclusions can be drawn of their source, so much does 
the size of the tubules vary in various conditions. It was formerly supposed that 
the beautiful corkscrew forms so often seen came from the convoluted tubules, 
but this is improbable, since any corkscrew shape would certainly be effaced during 
their passage through the straight tubules. Some are spiral all the length, others 
only at one end. This, says Senator, merely shows them composed of a tough 
elastic material which has been squeezed through a narrow canal or through a 
narrow orifice. The end of the cast is seldom split or forked. Some casts are 
almost on the limit of vision, but vegetable fibres must be excluded. 

The origin of epithelial casts, especially those with a lumen, is not disputed ; 
also that of blood and pus casts, which are conglomerates of cells in tubules. The 
coarser granular casts quite certainly are formed from epithelial casts by a granular 
degeneration of the cells, and all transitions from the coarsely granular casts to 
the waxy may be found. This transition may also occur in the leucocyte casts, 
but is less true of the blood-casts. Such transitions are followed best by the 
study of sections of the kidney. The origin of the hyaline casts, however, has 
long been in dispute, some claiming that they were a coagulated exudate from the 




Fig, 54. — Pseudo-casts. From left to right, a linen thread, a vegetable spine, a cotton thread, 
and a scratch on the glass slide. 



blood into the tubules, others a product of the secretion of the epithelial cells. 
Hyaline globules are present in these cells, the confluence of which in the tubules 
could easily explain casts; that is, the very slightly injured epithelial cell, still 
functioning, may by an abnormal secretion of coagulable material form these 
moulds of the tubules. This latter is the generally accepted idea. Also these 
epithelial cells could die, in part or wholly, undergo hyaline degeneration, and this 
substance be moulded into a cast. This also may be seen in sections. They are cer- 
tainly not coagulated fibrin, since they arise where there is no suspicion of inflam- 
mation, that is, in a practically normal kidney, as in the albuminuria of the new- 
born; they do not give the Weigert's fibrin stain; where a coagulable albumin is 
present, as in the case of chyluria, these casts are absent ; also there is no relation 
between albumin and casts in amount, and one may be present without the other. 
There is therefore no evidence for the albumin of the blood as their source. It is 
possible that a difference in origin explains the two forms of hyaline casts. Since 
casts which remain long in the tubules in cases where hyalines are the rule are 
waxy, the transition from hyaline to waxy must be considered. 

The origin of haemoglobin casts is interesting, since haemoglobin is soluble in 
the urine. It may be, however, that they are hyaline or waxy casts impregnated 
with haemoglobin. 



18 



274 



CLINICAL DIAGNOSIS 



The chemistry of the cast is little studied ; probably none are fibrin. 
Some give an amyloid reaction when there is no such degeneration of 
the kidneys. Amyloid disease rarely has such casts. Some react 
reddish to gentian-violet, and brownish to Lugol's fluid, but a good 
Lugol reaction is rare. Their solubility in acetic acid is an important 
point in excluding mucus cylindroids. 

Diagnostic Importance of Casts. It is claimed that casts may be 
present in normal urine. This is considered quite doubtful. They 
occur in any condition where albumin does or might occur, and it is 
agreed that any great number, even of hyaline cysts alone, means an ir- 
ritated condition of the kidney, although a few may not. But although 
usually associated with albumin, either one may be present without the 
other. Osier has emphasized the point that in diagnosis it is not so 
much the casts, their number and variety, which are of prime impor- 
tance as other urinary features (low specific gravity, etc.) and the 
physical signs of the patient. 154 Casts always mean, it is thought, 
some pathological condition of the renal epithelium, although this 
may be very slight, as a temporarily disturbed nutrition, but not neces- 
sarily nephritis. Their chief occurrence is in nephritis, but a similar 
urine picture is seen also in congestion of the kidney and in slight 
circulatory changes. In cases of albuminuria not due to nephritis casts 
may fail, and some (Bard) say when they cease in nephritis the in- 
flammatory process has stopped. Their number is greatest in acute 
and chronic parenchymatous nephritis, fewest in contracted kidney, 
amyloid disease (see page 314), and in chronic passive congestion, 
While they may mean merely a temporarily disturbed nutrition of 
the cells, on the other hand they may mean their total destruction. 
The fatty, epithelial, or hyaline casts with fatty cells attached indicate 
a degenerative process. Casts with leucocytes attached may mean 
inflammation; blood-casts, hemorrhage, etc. In nephritis the casts 
and albumin, as a rule, run parallel. Exceptionally the casts may fail 
in a true nephritis, as in a case of jaundice or arteriosclerosis. Another 
very good illustration is the transitory albuminuria of pneumonia. 
With a failure of albumin the casts may persist. This is considered 
common in very contracted kidneys. In this connection it is to be re- 
membered that casts will rapidly dissolve in the urine, and hence the 
presence of albuminuria without casts is not nearly so interesting 
as is the reverse condition. This disappearance of the casts may be 
easily demonstrated by comparing the urine after it has stood for 
some time, even though it remains clear, with that which is centri- 
fugalized and the sediment examined while the urine is still warm. 
This disappearance of the casts has been attributed to the ferments 
present in the urine. Certain it is that if pepsin be present the casts 
154 New York Med. Jour., November 23, 1901. 



THE UEINE: SEDIMENTS 



275 



could not remain there long. Trentlein says it is not pepsin but bac- 
terial (colon bacillus) ferments. 

" Showers" of casts are especially interesting. If a case of ne- 
phritis be followed daily, on certain days large numbers of casts will 
be found, and then in a day or so very few. Unless repeated exam- 
inations are made, a good idea of the number of casts cannot be 
gained. 

The presence of casts without albumin is not rare if one centrifu- 
galize well the urine. Such cases of pure " cylindruria" seem due to 
some evidently slight irritation of the kidneys, due to foods — aspara- 
gus, radishes; to coffee, mustard, and alcohol (Glaser found, after an 
even mild use of alcohol in some cases, casts and leucocytes, 
calcium oxalate and uric acid crystals, the effect lasting about thirty- 
six hours) ; certain drugs, especially well studied after salicylic acid, 
mercury, inunctions, Fowler's solution, and camphor ; after tuberculin 
injections; in valvular heart disease and arteriosclerosis; in cancer; 
in the milder grades of certain diseases, erysipelas, tuberculosis of the 
lung, diseases of the nervous system; in jaundice especially; constipa- 
tion and diseases causing constipation (confirmed by Wallerstein in 
animals) ; inflammatory intestinal diseases; acute infections, espe- 
cially typhoid and scarlet fevers ; even in a case of ursemic convulsions 
with recovery (Tonelli) ; and in amyloid disease sometimes. In the 
above cases the casts are hyaline and granular, even epithelial, and 
blood-casts, and yet no albumin. In some of these cases there is 
perhaps the possibility that the urine, had it been diluted, would have 
given the test. For the past two years we have paid this point particu- 
lar attention and examined all in the hospital in which this condition 
was present, and we find that in many cases of transient albuminuria 
the cylindruria will outlast the albuminuria. This is particularly true 
in those cases of mild nephritis to be attributed to a parenchymatous 
lesion; that is, to an acute process. In cases of arteriosclerosis we 
find that the reverse is more common, and have even seen cases in 
which this point has been of diagnostic value. The occurrence of 
casts and " nucleo-albumin" is a very common occurrence (see page 
221). 

In a case ot brain tumor recently in our wards the urine contained waxy and 
epithelial casts and many cylindroids, yet no albumin. 

It is very interesting that Miiller, in connection with the " physio- 
logical" albuminuria of bicycle racers, mentions one case with many 
casts but no albumin. Sometimes the cylindruria is very transitory, 
lasting but thirty-six hours. 

Pure cylindruria occurs in some cases of chronic nephritis and of 
amyloid kidney. Steward tries to separate a group of severe nephritis 



276 



CLINICAL DIAGNOSIS 



cases which presents this feature, but the anatomical evidence for such 
a group is still lacking. 

In cylindruria not due to nephritis the casts are few, and those 
found are hyaline, as a rule. 

The casts of chronic passive congestion are scanty if any, and 
nearly all are hyaline. Yet all gradations occur between this condi- 
tion and true nephritis. 

It was formerly supposed that the epithelial and the hyaline casts 
meant an acute process, the granular and the waxy a chronic process ; 
but in any form of nephritis all kinds of casts may occur; in amy- 
loid disease even there is in the urine nothing characteristic. Sahli 
suggests that the granular and the waxy casts become such from 
lying a long time in the tubules, which occurs in acute nephritis or 
acute exacerbations of a chronic case, in which the secretion of urine is 
much suppressed. We have noticed this point also in other oligurias 
following, for instance, decapsulation of the kidneys. For the first 
few days, as the urine begins to increase in amount, a very large num- 
ber of waxy casts were found. 

Following renal disturbance of almost any kind casts may appear. 
Brown 155 has reported some interesting cases in which operations 
upon the kidney, nephropexy or exploratory nephrotomy, the urine 
previously being normal, were, the first day after the operation, fol- 
lowed by an output of casts in enormous numbers. These were 
hyaline, granular, blood, and epithelial. The field may be really 
crowded with them. Considerable albumin may be present. They 
diminish rapidly in amount, and in a few days (from two to six) have 
entirely disappeared. During this time there have been no symptoms 
of nephritis, no cedema, and the amount of urine has been normal. 
The most striking urinary feature was the disproportion between the 
amount of albumin and the number of casts, this being greatly in favor 
of the latter. There were no later symptoms. 

Epithelial and leucocyte casts are not nearly so rare as is imagined, and may 
occur in even non-inflammatory transitory cylindrurias. 

Casts are considered important as a prodromal symptom of dia- 
betic coma (Kiilz). Before the coma begins casts appear in immense 
numbers, and even may form a macroscopic sediment. These casts are 
of characteristic appearance, — short, broad, of delicate outline, pale, 
the most of them granular and hyaline, and with few other formed 
elements. 156 

Staining Casts. — This is unsatisfactory, because the stain precipitates in the 
urine, or the albumin of the urine may itself take the stain. The specimens cannot 

155 Johns Hopkins Hosp. Bull., May, 1900. 

156 See Domansky and Reimann, Zeitschr. f. Heilk., 1901, and Herrick, Am. 
Jour. Med. Sci., vol. cxx. 1900. 



THE URINE: SEDIMENTS 



277 



be dried for this reason. The casts should be washed by one or two sedimenta- 
tions with 0.6 per cent, sodium chloride solution to rid of all soluble matter and 
albumin. In the next centrifugalization i per cent, methylene blue may be added. 
To hasten centrifugalization a little alcohol should be added, not much, nor allowed 
to remain in contact with the sediment for a long time, else a coagulum will result. 

To preserve the casts and also to stain them they should be washed in the 
above normal salt solution, and lastly in a i per cent, osmic acid solution or in i to 
10 per cent, formalin, or in a 5 per cent. HgCb solution for five minutes. In the 
latter case they are then washed with water and preserved in from 2 to io per 
cent, (or I to 2 per cent.) formalin. If no red blood-cells are present, the mercuric 
chloride may be omitted. This salt disturbs microchemical tests. In case formalin 
is used the casts should be well washed once or the spherical crystalline masses 
of diformaldehydurea will form. Gumprecht adds that it is not really necessary 
to wash the casts if they are well centrifugalized and the supernatant fluid com- 
pletely decanted. A good staining method for fat and cell nuclei was described 
by Cohn. 157 The specimen, well washed by centrifugalization in normal salt solu- 
tion, is air-dried on the cover-glass and hardened by immersing the glass in io per 
cent, formalin for ten minutes. It is then washed rapidly but gently with H 2 0 and 
then immersed for ten minutes in a concentrated Sudan III. solution in 70 per cent, 
alcohol. It is then washed in 70 per cent, alcohol for one to two minutes and 
then stained briefly in the hematoxylin (Ehrlich's). The specimens are mounted 
in glycerin. 

Kozlowoski 158 recommended Farrant's mounting fluid, consisting of equal parts 
of water, glycerin, and saturated aqueous solution of arsenic acid (saturated by 
weeks of standing) ; to this gum arabic one-half volume is added, and the whole 
allowed to stand (about three weeks) till all is dissolved. It is then filtered 
if necessary. 

In the centrifuge tube are mixed 1 cm. of 1 per cent, eosin or methyl violet 
with the urine, then centrifugalized and washed by centrifugalization till all the 
urine is removed. One drop of sediment is then mounted on the slide with one 
drop of the above fixing fluid. 

Bohland advises to wash with salt solution ; then Miiller's fluid is added, and 
they kept in this for two weeks, changing the fluid two to three times. The 
Miiller's fluid is then decanted and the sediment washed in absolute alcohol until 
this is colorless. 

Testicular Casts. — In " spermatorrhoea" casts have been described 
which " can hardly be distinguished from renal casts except that the 
urine is otherwise normal. They are all in the first glass of the two- 
glass test, and the presence of spermatozoa will indicate their origin. 
They are supposed to arise in the testicle." We have inquired of 
those with a very wide experience in the examination of prostatic 
secretions, and they say they have never seen such structures. Sper- 
matozoa may often be found, active at first, and with all of the ele- 
ments of unripe semen. They soon go to pieces. Such occur not 
only after coitus and pollution, but after epileptic and other convulsive 
seizures. 

Tripperfaden. — These occur in a late stage of acute gonorrhoea 
and in chronic gleet when the secretion becomes very mucous and 
collects in the longitudinal furrows of the mucosa. They may be from 
a few millimetres to one centimetre long and yellow or white in color, 

157 Zeitschr. f. klin. Med., 1899, Bd. 38. 

138 Virchow's Arch., 1902, vol. clxxix. p. 161. 



278 



CLINICAL DIAGNOSIS 



consisting of a mucous ground substance in which are embedded pus 
and epithelial cells. 

Tissue fragments, portions of carcinoma, have been found; also 
masses of caseous matter in cases of tuberculous ulceration. The elas- 
tic tissue may be demonstrated, and in the case of cancer the spindle 
cells, which may enclose haematoidin crystals and red blood-corpuscles. 
To demonstrate elastic tissue the urine should be centrifugalized, acid 
added to dissolve the phosphates, the supernatant fluid decanted, and 
the sediment then warmed with an equal amount of 10 per cent. KOH. 
This destroys all but the elastic tissue. It is then sedimented again 
and examined microscopically. 

In papillomatous cancers and growths of the bladder fragments 
large enough to be cut in sections may be found. They have been found 
in the urine especially of cases of carcinomata of the bladder, very 
rarely of the kidney. From some of these a diagnosis could be made. 
Fragments of sarcomata in the urine are almost unknown, but struc- 
tureless masses have been found, as by Rothschild, 159 from a giant-cell 
sarcoma of the kidney. This large mass was 5.2 cm. long and 0.5 cm. 
wide, structureless, glassy, transparent, and quite firm. 

Other gross masses are mucous casts (see page 221), and fibrin 
masses in chyluria, hsematuria, and from inflammatory conditions, 
especially tuberculosis. 

Pus-Cells. — These occur, a few perhaps, in normal urine, but 
many in any inflammation of the urinary passages, of the kidney, or in 
case an abscess ruptures into the urinary tract. Their numbers vary 
enormously. As a rule, if from the cortex of the kidney, they are 
few in number, if from the passages, many. 

Hottinger found in a case of cystitis 150,000 leucocytes per cubic 
centimetre, that is, a daily output of about one one-hundredth the 
number of leucocytes normally at one time in the circulating blood. 

Their origin is better indicated by other constituents, as, for in- 
stance the character of the epithelial cells or the presence of casts. 
In case a large amount of pus appears suddenly, the probable source 
is ruptured abscess. The pus-cells in gonorrhoea may be mixed with 
mucus, form threads, the so-called Tripper fiiden which probably are 
formed in the folds of the mucosa and are washed out by the stream 
of urine. These Tripper faden will settle to the bottom of the glass. 
They should be searched for only in fresh specimens by agitating the 
urine, when they arise as long threads, since if allowed to settle long 
they will coalesce. They have a considerable diagnostic value. 

In all cases of women pus from the vagina should be excluded. 

In alkaline urine the pus-cells will swell and the mass become 
slimy and gelatinous. The pus sediment is, as a rule, slimy, since it 
159 Deutsches med. Wochenschr., 1901, No. 50. 



THE UKLNE: SEDIMENTS 



271) 



contains so much mucus. Albumin is always present. Microscopi- 
cally in acid urine the cells may be cloudy and shrunken, and acetic 
acid be necessary in order that the nucleus may be seen at all. In 
an alkaline urine they will swell and become glassy, but even here it 
is not easy to see the nucleus. In a weakly alkaline, amphoteric, or 
faintly acid urine they may be well preserved for a long time, and 
even show active amoeboid motion. Their diameter is from 7 to 12 
microns. Their nucleus is small, usually polymorphous, never vesic- 
ular. This will exclude renal epithelium, which it is often hard to do 
except in stained specimens. (Senator considered that many of the 
pus-cells in Bright's disease were mononuclears.) 

We have had opportunity recently to examine two cases in which the leucocytes 
were so drawn out that they resembled spindle epithelial cells. This may have 
been due to long centrifugalization in one case. This was true of practically all 
the leucocytes and on two preparations. 

It is often important to decide whether there is more albumin than 
the pus serum would explain; that is, if true albuminuria is also pres- 
ent. In case casts and renal epithelium are found a cortical origin for 
some at least of the albumin may be assumed. 

Posner's Method. — The albumin is estimated carefully. The urine 
is well shaken (a twenty-four hours' specimen) and the leucocytes 
counted with the ordinary blood-counter. For each 100,000 leucocytes 
per 2 cc. of urine, one may expect o. 1 per cent, albumin 
(Goldberg, 2 p. M.). The urine must be diluted with 1 to 3 per 
cent. Nad solution if over 3000 per cubic millimetre are present. 

The same author has given an easier method which is of some 
value. The urine is poured into a flat-bottomed beaker which is 
placed over a sheet of ordinary printed paper. The well-shaken urine 
is then poured in until the type cannot be read. Normally one can 
read through a layer of urine 8 cm. deep ; if the type cannot be read 
when the layer is from 0.5 to 1 cm. it indicates 40,000 leucocytes per 
cubic centimetre; if 6 cm., 1000 leucocytes per cubic centimetre. The 
benefit of treatment may be followed by this method. A former idea, 
that the filtrate of a urine without true albuminuria is albumin-free, is 
hardly true, although the albumin in the filtrate is of very small 
amount. 

Donne's Pus Test. — The supernatant fluid is poured off", and to the 
sediment a small piece or strong solution of KOH or NaOH is added. 
If the sediment is pus it wall be transformed to a viscid gelatinous mass 
which sticks to the glass. 

The pus-cells will take a mahogany-brown color with Lugol's. 

Red Blood-Corpuscles apart from True Hematuria. — These are 
present in the urine in acute inflammations of the kidney, tumors of 
the urinary passages or kidney, in cases of trauma, stone, chronic pas- 



280 



CLINICAL DIAGNOSIS 



sive congestion, the hemorrhagic diathesis, and in many trivial condi- 
tions in which they would not be expected. Some of the cells are 
intact or they may be changed by the urine. It is particularly com- 
mon to see merely shadows or rings of the swollen decolorized cells. 

In concentrated urines they are crenated; in dilute, swollen or 
laky; in acid urines, intact; in alkaline, destroyed, forming masses 
of yellowish-brown granules. 

It is important to decide if these cells come from the cortex of the 
kidney or not. A cortical origin may be assumed if many red blood- 
cells are sticking to casts or if true blood-casts are present. An amount 
of blood sufficient for clot formation usually has its source below the 
cortex, but sometimes in nephritis enough blood may escape from the 
cortex to form large clots, the shape of which will sometimes indicate 
the source, it being a cast of the pelvis or of the ureter. 

Gumprecht claimed that if many of the reds were found frag- 
mented, that is, present as clumps of granules, the source in the cortex 
is to be assumed, since here alone the urea solution is strong enough to 
fragment the reds (8 per cent.). Goldberg thinks that these cells 
can become fragmented in a distended infected bladder. 

Renal and Bladder Stones. — By renal stones are meant all from 
the pelvis of the kidney and the ureter. They vary in size from a grain 
of sand to those which fill the whole pelvis of the kidney. These 
large ones with the branches may be hollow, furnishing thus a passage 
for the urine (in one case it weighed 1088 grains). The bladder con- 
cretions are single or multiple, and vary greatly in size. 

Uric Acid Concretions. — These are very common, the most common 
renal stone. The size of those found in the bladder varies from that 
of a pea to that of a goose-egg. They are always colored, most com- 
monly a grayish yellow, yellowish-brown, or a pale reddish-brown. The 
surface is sometimes smooth and polished, sometimes rough and nodu- 
lar. They are very hard, fracture easily, and on cross-section they 
show a concentric arrangement and crystalline structure, the layers of 
which may be separated being of different colors. These layers may 
be alternately of uric acid and some other salt, as, for instance, CaOx. 
They burn without residue if pure, they give the murexid test, on the 
addition of NaOH they liberate but little ammonia, are soluble in 
alkali, and this solution plus acetic acid gives crystals for the murexid 
test. 

Ammonium urate stones are primary in the new-born, and occur 
rarely in adults. As secondary deposits they occur more commonly. 
These stones are almost as soft as wax, when dry are clayey and easily 
powdered. They give the murexid test and with NaOH liberate much 
ammonia. 

Calcium oxalate stones are, next to uric acid stones, the most common, 



THE UELNE 



281 



and yet seem the most numerous, since they cause severest symptoms. 
They are either smooth and small or very large with a rough nodular 
or ragged surface, of a dark gray to blackish color. They cause hemor- 
rhage easily, and hence are often stained dark brown with blood-pig- 
ment. They are the hardest and heaviest of stones. They are soluble 
in HC1 without gas formation, but not in acetic acid. After moderate 
heating, however, the powder is soluble in acetic acid with gas evolu- 
tion. After strongly heating, the powder reacts alkaline because of the 
Ca(OH) 2 formed. They contain almost always some uric acid, 
xanthin, or calcium carbonate, and hence have a concentric layer 
arrangement. 

Phosphate Stones. — As renal stones they are rare and small, yet 
often occur as ingredients of other stones. They usually consist of 
a mixture of normal phosphates of the alkaline earths and triple phos- 
phate. In the bladder they may be very large. They occur especially 
as secondary concretions, and contain ammonium urate, CaOx, and 
carbonates. They often form around a foreign body. Their color 
varies, — sometimes white or pale yellow, or purplish. They are soft, 
light in weight, the surface always rough. Concretions of triple phos- 
phate alone are rare. They are small with a granular surface, upon 
which are often red crystals. Stones of the acid calcium phosphate 
are rare. They are white and of a beautiful crystalline structure. 
These phosphate stones do not burn, the powder is soluble in acetic 
acid without gas formation, and the solution gives the reaction of 
phosphoric acid and of alkaline earths. They usually contain a great 
many organisms. The triple phosphate stones liberate much 
ammonia on the addition of NaOH. 

Calcium carbonate stones are rare in man, are chalky white, soluble 
in acid with gas formation. 

Cystin stones are rare. Their size varies, and may reach that of a 
hen's egg ; as renal concretions they are seldom larger than a small pea. 
The life of some of the cases of cystinuria is wretched because of the 
rapid formation of stones large enough for operation. They are light 
in weight, smooth, soft and waxy in consistency, hence may usu- 
ally be crushed. They have a smooth or ragged surface, are white or 
pale yellow, and crystalline on cross-section. They are rather wax- 
like, burn readily and perfectly on a platinum-foil with a bluish flame, 
are soluble in ammonia, recrystallized by acetic acid, and give the other 
cystin reactions. 

Xanthin stones are very rare and occur especially in children. This 
is also a primary formation. They vary in size from a pea to that of a 
hen's egg. They are pale white, yellowish-brown, rather hard, amor- 
phous on cross-section, and on rubbing appear like wax. They burn 
without residue on the platinum-foil, and give the xanthin test. 



282 



CLINICAL DIAGNOSIS 



Fatty concretions have only a few times been observed. They con- 
tain free fatty acid, neutral fat, and much cholesterin. In some cases 
these have been found to be of the fat used in passing bougies. 

Indigo. — Three such stones are on record, and yet this may be the 
nucleus of various other stones. They have a blue or bluish-gray sur- 
face. 

Albumin. — One such calculus is on record. 

WHEN HEATED ON THE PLATINUM-FOIL THE POWDER 



(hofmeister's table.) 



Does not burn 


Burns 


The powder + HCl 


With flame 


Without flame 


Does not effervesce 

The powder moderately 
burned + HCl 


Effervesces. 


The flame is yellow, continuous, odor of burning feathers. Insoluble 
in alcohol and ether ; soluble in hot KOH, and repiecipitated unite 
by acetic acid, with H 2 S formation. 


A yellow, clear continuous flame, odor of resin or shellac ; the 
powder soluble in alcohol and ether. 


Flame pale blue, burns for a short time with a characteristic sharp 
odor. The powder is soluble in NH 4 OH and on evaporating hexa- 
gons are precipitated. 


Does not give the murexid test. The powder is soluble in HN0 3 
without gas effervescence, and this dried residue becomes orange 
when KOH added, then red on warming. 


The 
powder 
gives the 
murexid 
test. 


Does not e 

The native 
moistene< 
KO 

IT) 

O 03 Hp? 
ft- X 

*> S 
X ^X 

u5 D 
3 ^ "S 

C 03 .tJ 

° CD £ 
£2 °- 

5 £;p 


ffervesce 

powder 
i with 
H 

•-a 

V c n 
o 1 £ 

H ^ 

i« * 

ol « 
°- ft 

tJ X <p 

.Th J-c 

— eft 

en 

O cu p 

tn *n O 

3f P^ 
— ft 

O g o 


Effervesces. 


T 

nal 
pov 
on 
add 
of a 
KO 
the 

X 

u 
p 

a 

o 

<v 
> 

O 


he 

:ive 

vder 

the 

ition 

little 

H in 

cold 

X 
o 

G 
i-i 

o 

5 
o 

CD 
> 

3 


Triple phosphate 


Neutral Ca or 
Mg phosphate 


CaOx 


6 
u 

03 

u 


Fibrin 




Cystin 


Xanthin 


Ammonium urate 


Uric acid 



THE URINE: BACTERIA 



283 



THE BACTERIOLOGY OF THE URINE 

The urine when examined is usually rich in bacteria of many 
varieties. Some of these may have been in the urine when it was 
voided, but the most are contaminations from the external genitalia, 
from the vessels which hold the urine and from the air. The urine is 
an excellent medium for many saprophytic organisms, and evidently 
for many pathogenic organisms as well. It is for this reason that, 
unless especial care be taken to prevent their access and growth, the 
urine is soon unsuitable for microscopical study. Specimens to be 
studied chemically should be preserved in clean bottles ; chloroform, 
camphor, thymol, formaldehyde, etc., should be present in the bottle 
from the first and the specimen should be kept in an ice chest as much 
of the time as possible. Specimens to be studied microscopically should, 
whenever possible, be examined at once after voiding. And, lastly, 
if the specimen is to be studied bacteriologically, too great care cannot 
be taken to collect the urine in a way which prevents contamination. 

The Technic of Obtaining Specimens for Bacteriological 
Study. — It is not always or often necessary to catheterize the male 
patient, especially if he is intelligent enough to aid us by observing 
the necessary precautions. The glans penis, and especially the edges 
of the urethral orifice, are thoroughly washed with green soap and 
water, and then with bichloride of mercury ( i : 1000). The anterior 
urethra is then well irrigated with bichloride of mercury (i : 60,000). 
The patient then voids ; the most of the urine is allowed to escape, com- 
pleting the irrigation of the tract, and the last few cubic centimetres 
are collected in a sterile test tube. A way preferred by some is to ask 
the patient to void into three sterile glasses. The third is the speci- 
men examined. 

It is necessary to catheterize the female patients. The external 
genitalia, and especially the orifice of the urethra, are well washed 
with green soap and water. The orifice of the urethra is then repeat- 
edly mopped with sterile cotton pledgets soaked in sterile water, boracic 
acid, or mercuric chloride. At least ten or twelve of these pledgets 
should be used. A sterile glass catheter is then inserted with care that 
it touches only the orifice of the urethra. The hands of the person 
introducing it should be surgically clean. Over the free end of the 
catheter was previously fitted a rubber tube, large enough to fit loosely 
and about four inches long. After the most of the urine has escaped, 
this rubber tube is slipped off and the last small portion of urine col- 
lected in a sterile test tube. This rubber tube protects the tip of the 
catheter from contamination. 

Bacterioscopic Examination of the Urine. — This is by far 
the most important part of a bacteriological examination of the urine 



284 



CLINICAL DIAGNOSIS 



and should be done when cultures are also made, since by this we 
may get a hint as to what culture media will best serve our purpose, 
may discover the presence of the bacteria which will not grow on the 
media used, and those which have already died. 

Two of the reasons why smears of urinary sediments are not 
oftener studied for bacteria are that it is difficult to obtain good film 
preparations unless all the urea, which is very hygroscopic, has been 
previously washed out from the sediment; and, secondly, that it is 
difficult to clear a urine clouded by bacteria by sedimentation or even 
by centrifugalization, since the specific gravity of their bodies is so 
nearly the same as that of the urine. And yet in the great majority 
of cases, especially those with even a little pus present, there is little 
difficulty in getting good smear preparations. One centrifugalizes the 
urine on a rapid machine until there is even a little sediment at the 
point of the tube, then quickly inverts the tube and allows all the 
urine to escape and drain. While still holding the tube in a perfectly 
vertical position a little of the sediment is scraped from the tip of 
the tube with a platinum loop. One must be careful to invert the tube 
quickly, and then while the urine is draining and while scraping the 
sediment with the loop not to incline it at all, else urine clinging to the 
sides of the tube may flow to the point and so the smear contain 
urinary salts. 

But in case the urine is very clear and one wishes to exclude the 
presence of organisms, one dilutes it with one, or even two, volumes 
of alcohol. This will so lower its specific gravity that practically all 
the organisms will be thrown to the point of the tube. This fluid is 
very thoroughly centrifugalized, the supernatant fluid poured off, more 
alcohol or distilled water added, the contents of the tube well shaken, 
and then again centrifugalized. (There is danger that many of the 
organisms will be left sticking to the sides of the tube rather than 
be thrown to its point. To avoid this, some allow a considerable 
amount of the mixture of urine and alcohol to sediment in a beaker 
and then centrifugalize the sediment.) The sediment will now be free 
from urea, and satisfactory smear preparations on a glass slide or 
cover glass can be made. It is often wise, in case but little sediment 
is present, to add a little egg albumin which will stick the bacteria to 
the glass. 

The smear preparation is first dried in the air, then passed slowly 
through the flame of a Bunsen burner or alcohol lamp three times, 
and then stained. 

Bacterial Stains. — The bacterial stains in common use are solutions of the 
basic aniline dyes (Griibler's are the best). 

LoiHer's Methylene Blue. — Saturated alcoholic solution of methylene blue 30 cc, 
aqueous solution KOH (1 : 10,000) 100 cc. 



THE URINE: BACTERIA 



285 



The film is covered with this stain and heated over the flame for from one 
to five minutes. When no heat is used the staining will take much longer. The 
stain is then washed off with water, the film dried with blotting or filter paper, 
and then mounted in Canada balsam. If on a slide the smear may be studied 
without the interposition of a cover glass. 

Saturated Aqueous Solution of Methylene Blue. — This is used as the above, 
but stains a little more slowly. 

Aniline Gentian Violet. — Aniline oil water is first made by adding exactly 2 cc. 
of aniline oil to 98 cc. of distilled water in a flask. This is shaken vigorously 
till as much as possible of the oil is dissolved, and filtered twice through the 
same paper. This fluid is kept in a dark-glass bottle and in a dark place. 

To 75 cc. of this aniline oil water are added 25 cc. of a saturated alcoholic 
solution of gentian violet, and the mixture filtered. This staining mixture is 
fairly permanent, but should not be exposed to strong sunlight and should be 
occasionally filtered. Smears will stain readily in this in a few minutes. This is 
the stain used in Gram's method (see page 85). 

Piffaud's Method of Staining Bacteria (N. Y. Med. Jour., Nov. 2, 1907). — This 
is a valuable method for determining the nature of a growth. 
Cyanide blue solution : 

Distilled water 100 parts 
Potassium cyanide (pure) 1 part 
Potassium carbonate (dry; pure) 0.5 part 
Rectified methylene blue 0.5 part 
A small drop is placed on the centre of a slide, and then a loop of the growth 
well mixed with it. After one minute a clean cover glass is dropped on, and the 
excess of the moisture absorbed by pressing the cover glass firmly with a piece 
of filter paper. In this way one dispenses with drying, heating and long staining. 
Carbolfuchsin. — 

Basic fuchsin 1 part 
Absolute alcohol 10 parts 
Carbolic acid solution (1:20) 100 parts. 
This is a very powerful stain. When used undiluted from one-half to one 
minute's staining is sufficient, but better results are obtained when it is diluted 
with from 5 to 10 volumes of water and left in contact with the smear for a few 
minutes. This is the stain used for the tubercle bacillus (see page 50). 
Bismarck Brown (see page 62). 

Staining Methods for Acid-Fast Bacilli (see page 50). 
Gram's Method (see page 85). 
Capsule Stains (see page 59). 

Spore Staining. — The film is first placed in chloroform for two minutes and 
then well washed in water. It is next placed in a 5 per cent, solution of chromic 
acid for from one-half to two minutes, and again well washed with water. It is 
then stained with carbolfuchsin while heating jn the same manner as if one were 
staining the tubercle bacillus (see page 50). The carbolfuchsin is not washed 
off in water, but with 1 per cent, sulphuric acid, or with methylated spirit (Ethyl 
alcohol 9 parts, methyl alcohol 1 part), and left in this until decolorized. It is 
then washed in water, stained with a saturated aqueous solution of methylene blue 
for half a minute, washed again in water, dried, and mounted in balsam. The 
spores will retain the red stain, the bacilli will take the blue. 

Flagella Staining. — It is very difficult to get good results since only under 
certain conditions of growth, age, etc., can the flagella be demonstrated, and even 
when the culture is a very suitable one, the flagella may be very easily injured 
by technic. The smear should always be made from a young agar culture, incubated 
at 37 0 C. for from 12 to 18 hours. Kendall recommends to inoculate gently 5 cc. 
of sterile water with enough of the above-mentioned growth to produce a faint 
turbidity in the upper half of the tube. This tube is then placed in a thermostat 
for one hour. This will allow the clumps to settle and the organisms to multiply 
a. little. Without disturbing the 'fluid any more than one can help, two or three 



286 



CLINICAL DIAGNOSIS 



loopfuls are removed and placed on a clean cover glass without spreading and 
dried in a thermostat. The specimen is then fixed in a flame. (The cover glass 
should be one which has been washed in a mixture of concentrated sulphuric acid, 
6 parts, potassium bichromate, 6 parts, and water, ioo parts. It should then be 
washed thoroughly in water, and stored in absolute alcohol.) 

The staining methods are all of them so unsatisfactory that the best is usually 
the one with which the worker is most familiar. (For Loffler's and other methods 
see Muir and Ritchie, Manual of Bacteriology, 1903, American Edition.) 
Pitsfield's Method as Modified by Richard Muir — 
The mordant consists of : 

Tannic acid, 10 per cent, aqueous solution, filtered, 10 cc. 

Alum, saturated aqueous solution, 5 cc. 

Corrosive sublimate, saturated aqueous solution, 5 cc. 

Carbolfuchsin stain (see page 283), 5 cc. 
This is mixed thoroughly. A precipitate forms which is allowed to settle, or the 
fluid is centrifugalized, and the clear supernatant fluid removed with a pipette and 
kept in a clean bottle. This will keep for one or two weeks. 
The stain is, 

Alum, saturated aqueous solution, 10 cc. 

Gentian violet, saturated alcoholic solution, 2 cc. 
This should be not more than 2 or 3 days old when used. 

The film prepared as described above, is covered with as much of the mordant 
as the cover glass will hold, heated over a flame and allowed to steam gently for 
about one minute. It is then well washed in running water for about two minutes. 
It is then carefully dried over a flame, then covered with the stain, heated, allowed 
to steam for about a minute, washed well in water, dried and mounted. 

Study of the smears of the sediment will give some clew as to the 
presence of organisms and the nature of some of those seen. For 
some organisms it is the best method of study we have. This is espe- 
cially true of the tubercle bacillus and streptococci. 

Bacillus tuberculosis (for staining methods see page 50) may 
be found in the urine in cases of tuberculosis of the kidney or of any 
portion of the urinary tract, providing the tuberculous focus is dis- 
charging into this tract. The disease may be extensive in a kidney, 
e.g., but if a focus has not ulcerated into the pelvis of the kidney, or 
if that kidney is not secreting any urine, no tubercle bacilli will be 
found in the urine. But tubercle bacilli are not infrequently found 
in the urine of patients with miliary tuberculosis,* and some think 
they can be found in the urine of patients with pulmonary tuberculo- 
sis, or in fact with tuberculosis of any organ, and that their presence 
does not indicate local tuberculosis of the urinary tract unless pus 
also is present in the urine, or there are other signs of local tubercu- 
lous disease. Cases of sterile pyuria are often due to tuberculosis. 

The Smegma Bacillus is an organism which grows in abundance 
on the external genitalia and wherever the secretions of the skin 
accumulate. Its morphology and staining characteristics vary some- 
what. Some of its strains closely resemble the tubercle bacilli, both in 
morphology and in its acid- and alcohol-fast staining reactions, so 

* Churchman. Am. Jour. Med. Sc., July, 1905. 



THE UEINE: BACTERIA 



287 



that the only sure method of differentiation is animal inoculation. 
Twenty-one different stains have been published to differentiate these 
organisms from the tubercle bacillus, but in vain. It is not necessary 
to differentiate between them. It is much easier to avoid them entirely 
by cleanliness in obtaining the specimens, and then any acid-alcohol- 
fast bacillus can safely be called Bacillus tuberculosis. 

Streptococci also are much more safely searched for in the smears 
from the sediment than by cultural methods, and no matter what the 
organism is, one should always control his cultures by a preliminary 
bacterioscopic examination. 

THE BACTERIOLOGY OF THE URINE, CULTURAL METHOD 

The last portion of the urine voided is well centrifugalized, without 
the addition of alcohol (see page 284), or sterile water may be added 
to dilute the urine and to wash the sediments, and cultures are made 
from the sediment. 

The culture medium used will depend in great measure on the 
organisms suspected. When, however, the nature of the organism is 
not known, blood agar is the best medium to use, since all organisms 
which can be cultivated will grow on this. A few loopfuls of the 
urinary sediment are rubbed over the surface of this medium and 
the tubes then inoculated at 37 0 C. The different colonies can then 
be distinguished and transplantations to suitable media be made. 

The media in common use are the following: 

Nutrient Agar. — About 1500 cc. of distilled water are heated slowly over a 
furnace in a large metal pan. Meanwhile 15 gm. of agar are shredded and added, 
together with 2.5 gm. of Liebig's meat extract. The heating is continued, stirring 
at intervals until all the agar is dissolved. All floating scum is skimmed off with 
a spoon. The pan is then removed from the fire, cooled slightly, and 10 gm. of 
peptone (Witte's) and 5 gm. of sodium chloride added slowly, little by little, 
stirring vigorously all the while to facilitate solution. The pan is then replaced on 
the fire and the contents boiled and stirred until all the peptone is dissolved. The 
reaction of the fluid is then made just alkaline (to litmus) by the addition of a 
5 per cent, solution of sodium hydrate. The pan is then removed from the fire 
and cooled to 6o° F. In the meanwhile the whites of two eggs have been mixed 
with 150 cc. of water. This is added to the agar solution, the pan then replaced 
on the furnace, and slowly heated until coagulation is complete: The fluid is not 
stirred during this coagulating process. When coagulation is complete, the pan 
and contents are weighed, and enough water added to bring the weight of the 
contents to just 1000 gms. (Twenty grams are allowed for the weight of each 
white of egg which will be filtered off.) 

Meanwhile a large funnel with rubber tube and pinch-cock on the nozzle has 
been set up on a retort stand. In this is placed a well-moistened filter paper folded 
in a wire holder. The contents of the pan are now poured into the funnel through 
a strainer which will remove the coagulum. The medium is filtered at once into 
tubes or into a flask and sterilized for seven minutes in an autoclave. 

If the medium filters too slowly, it is poured back into the pan, reheated, and 
filtered through a fresh filter paper. 

This is the medium most used for the ordinary specimens and also is the basis 
of other special media. 



288 



CLINICAL DIAGNOSIS 



Glycerin Agar. — This medium is similar to the above except that to it after 
filtration is added from 6 to 8 per cent, of glycerin. The medium is then tubed 
and sterilized in the autoclave for seven minutes. This medium is superior to 
plain agar (the above medium) since many organisms which grow delicately on 
the latter will grow well on this. This is true of streptococci, the meningococcus, 
the pneumococcns and the tubercle bacillus. 

Blood Agar. — This is one of the most valuable of media. 

Rosenau's Method. — About one hundred sterile slant tubes of plain agar are 
first prepared and then a flask containing 50 cc. of plain agar which is melted at 
from 40 to 6o° C. Just 15 cc. of human blood are added under aseptic precautions to 
the 50 cc. of melted agar, the contents of the flask well mixed by shaking, and from 
1 to 2 cc. of this are poured into each of the slant agar tubes. The tubes are then 
placed in the proper position that this agar-blood mixture may harden as a uniform 
layer over the plain agar slant. The technic must be aseptic to prevent contamina- 
tion of the tubes, since they must not be sterilized again. All the tubes are then 
left in the thermostat for a few days to be sure they are sterile. If made in this 
way a little human blood will make a great many tubes. 

Oh this medium will grow practically all organisms which can be cultivated at 
all. It is especially good for the gonococcus and Bacillus influenzae. 

Nutrient Gelatin. — This is made in practically the same way as is nutrient 
agar, with the substitution of from 100 to 150 gms. of "gold leaf" gelatin for 
the agar. This medium should, however, be boiled as little as possible and should 
be sterilized in the autoclave for but five minutes. (Of course tubes of this medium 
should not be placed in a thermostat kept at body temperature.) 

Litmus Milk. — About 100 cc. of fresh milk are allowed to stand in the refrigera- 
tor for about five hours and as much of the cream as possible removed. Then 
enough litmus tincture is added to give the milk a deep sky-blue color. The 
medium is then tubed and sterilized in the autoclave for seven minutes. 

Bouillon. — The formula is : 

Liebig's meat extract, 2.5 gm. 
Peptone (Witte's), 10. gm. 
Sodium chloride, 5 gm. 
Water, distilled, 1000 cc. 
The steps in the making of this medium are practically the same as those for 
plain agar. To the boiling water is added the meat extract and the boiling 
continued for five minutes. The pan is then cooled down a little, the peptone and 
salt added slowly and then dissolved by boiling, and the fluid made alkaline as 
described above. This medium when finished is first poured into a flask and sterilized 
in an autoclave for five minutes, then cooled, filtered twice through the same paper, 
then tubed and sterilized again in the autoclave for five minutes. 

LofFlcr's Blood-serum Mixture. — See page 84. 

Among the more important organisms which may be encountered 
in the urine are the following. We give a few of the important 
features of each and for more detailed description would refer the 
reader to any standard text book of bacteriology. 

Bacillus Coli Communis. — The colon group includes twenty or thirty very 
similar varieties, which usually are grouped under this one name. It is a short 
organism, the majority from 1 to 2 /J- long and 0.5 thick. Some, however, are so 
short as to resemble cocci and others are over 5 m long. It often occurs in pairs. 
It is a sluggishly motile bacillus, although its motility is not always evident and 
often cannot be demonstrated at all in cultures over 24 hours old. Some strains, 
however, are very motile. Its flagella are numerous and laterally placed. It 
stains well by all the usual aniline dyes and decolorizes by the Gram method. 
It does not produce spores. The organisms with unstained portions resembling 



THE UELXE : BACTEKIA 



289 



spores are involution forms. It grows rapidly on all media at room as well as at 
body temperature, and in a characteristic way. The growth on the surface of agar 
is abundant, thick, moist, and spreads rapidly. The deep colonies are very circum- 
scribed and opaque with a well developed nucleus. This bacillus does not liquefy 
gelatin and does not spread on the surface of this medium as on agar. The 
surface colonies on gelatin have a nucleus and well-defined granular or striated 
refractive halo. It turns litmus rapidly (within 18 hours) acid, coagulates it (in 
from 4 to 30 days) and does not later digest the clot. The growth on potato is 
abundant and visible. It ferments almost every carbohydrate known, but especially 
glucose, lactose, and saccharose, with abundant gas production. It produces indol. 
The colon bacillus is almost ubiquitous. It is the prevailing organism of the lower 
part of the small intestine and the colon, and is almost universal in soil, water, 
food, etc. It is a mildly pathogenic and pyogenic organism. It is the organism 
found most frequently in infections of the urinary tract. 

Bacillus Typhosus. — The typhoid bacillus is a long slender organism measuring 
usually from 2 to 4 ju in length and about 0.5 ^ in thickness. It is actively motile. 
Its rlagella are more numerous (from 5 to 20) and somewhat longer than those 
of Bacillus coli communis. It stains easily by all the aniline dyes and decolorizes 
by Gram's method. It does not produce spores. It grows on all ordinary media. 
The growth on agar is thin and translucent with slightly spreading dentate or leaf- 
like edges. The deep colonies have sharply defined edges and a distinct nucleus. 
Bacillus typhosus does not liquefy gelatin. Its growth on potato is often, but 
by no means always, invisible. (The colon bacillus grows on potato as a distinct 
brownish scum, and the typhoid bacillus may also. This seems to depend on the 
potato used.) A most important feature is the reaction of this bacillus on litmus 
milk. A very slight acidity is first produced, distinct, but never enough to coagulate 
the milk not even in weeks. This slight acidity may be permanent although some 
strains later furnish enough alkali to change the reaction back to neutral, or even 
alkaline. Certain carbohydrates, including dextrose, levulose, maltose and manr.ites 
are fermented to the point of acidity, but none with gas production. Saccharose 
and lactose are not at all affected. It does not form indol. 

For the certain recognition of this bacillus, its agglutination in the very dilute 
serum (1 : 50 to 1 : 1000 even) of a patient or animal immune to Bacillus typhosus 
is necessary (see page 293). 

This organism is often present in the urine, in even over one-third of all 
cases (see page 293) during typhoid fever, and in some cases for years afterward. 

The Paratyphoid Group of Organisms. — The more carefully are cases of 
" typhoid fever " studied bacteriologically, the more numerous are found to be 
the cases due not to Bacillus typhosus but to bacilli very similar to it, but resembling 
in some essential respects Bacillus coli communis. Those which stand nearest 
this organism are called paracolon bacilli. There is no one Bacillus paratyphosus, 
but a group. In the clinical laboratory of the Johns Hopkins Hospital are kept at 
least eleven different strains of this organism. They seem to stand between Bacillus 
typhosus and Bacillus coli communis, but the court of last appeal is the serum 
agglutination test, which is a fairly satisfactory means of differentiation, although 
they show in some cases a rather marked group reaction. 

The characteristic cultural features of the paratyphoid bacilli are their reaction 
to milk and to sugars. All resemble Bacillus typhosus in that they produce first a 
slight acidity in milk. Then all (and this may take weeks) finally change the 
reaction of the milk back to alkaline. The attempt to divide the group into the A 
group of organisms which keep the milk acid and the B group which change it back 
to alkaline, seems unjustified (Ford, Medical News, June 17, 1905). And they 
all ferment glucose with gas production. Some ferment also lactose, some sac- 
charose, but none all three sugars. But the court of last appeal is their reaction 
to the serum of animals immunized to one of the strains of these bacilli. This is 
fairly specific, although they do show a group reaction. 

Bacillus Lactis Aerogenes. — This is a short thick (about 2 ^ long and 0.7 
thick) non-motile, encapsulated bacillus. It occurs usually in pairs and sometimes in 
19 



290 



CLINICAL DIAGNOSIS 



chains. It often shows rather marked polar staining. It is decolorized by Gram's 
method. It is not a spore-producing organism. It produces on all media a 
luxuriant viscid, slimy growth which resembles in many ways that of Bacillus coli 
communis. It does not liquefy gelatin. It ferments practically all the carbohy- 
drates rapidly and with abundant gas production. This organism has been the 
subject of much dispute. Some do not distinguish it from Bacillus coli communis, 
some group it with the capsulated group. Some strains of this organism cannot 
be distinguished from Bacillus capsulatus of Friedlander (Bacillus pneumoniae). 

This bacillus is a normal inhabitant of the upper part of the small intestine, 
where it is the predominating organism. Some believe it the cause of certain 
cases of cystitis. 

Bacillus Alkaligenes. — This bacillus is a normal inhabitant of the intestinal 
tract. Its greatest importance is that it is often mistaken for Bacillus typhosus. 
It is a long, slender bacillus from 2 to 3 f* long and 0.5 v> thick, which grows 
singly, in pairs, or in chains. It is actively motile. 

It grows on all culture media. It does not liquefy gelatin. Its most char- 
acteristic cultural reaction is the production of an intense alkaline reaction in 
litmus milk without previous acid production. It ferments carbohydrates without 
producing an acid reaction and without gas production, and is the only one of the 
common intestinal flora which grows only in the open end of the fermentation 
tubes, and not at all in the closed end. 

The Proteus Group. — The members of this group, among which are Proteus 
vulgaris, Proteus mirabilis, Proteus Zenkeri, Proteus Zoffii. and other strains with 
but minor differences, are the most important agents of putrefaction. While secondary 
invaders as a rule, in certain cases of cystitis they are the pathogenic organism. 
In fact this is almost the only organism which when introduced into a normal 
bladder can set up cystitis. They are the important organisms in the production 
of " saprsemia," or intoxication from the products of decomposition, as from a 
portion of retained placenta. They are short, slender, actively, even violently, motile 
bacilli with terminal flagella. This description of the organism applies only to 
fresh cultures. If those a little older be examined, one will find in the smears 
cocci, bacilli of all sizes, spirilla, etc. The smear will suggest a badly contaminated 
culture. But if fresh transplantations be made and examined early, the organisms 
will be found to be bacilli of uniform morphology. The above polymorphism is 
explained by involution forms. It is decolorized (?) by Gram's method. It grows 
well at room temperature. The colonies on agar spread rapidly in a characteristic 
manner, the edges sending out peculiar, hair-like projections, and look like tufts 
of moss. Proteus vulgaris and mirabilis liquefy gelatin (the former rapidly, the 
latter slowly ) and blood serum rapidly. Proteus Zenkeri and Zoffii do not. Milk 
is coagulated and the clot then digested with the reaction alkaline. The strains 
differ somewhat in their ability to ferment sugars. The formerly much talked-of 
Bacterium termo is possibly one of this or of a nearly related group. 

Bacillus Pyocyancus. — Bacillus pyocyaneus is a small organism about 2 fi long 
and 0.5 M thick, actively motile, and which stains well in all ordinary bacterial 
stains, showing often a marked bipolar staining. It decolorizes by Gram's method. 
It grows rapidly on all ordinary media and will crowd out any other organism which 
happens to grow along with it. Its characteristic cultural characteristics are. that 
it will not split up carbohydrates, that it liquefies gelatin and blood serum rapidly, 
that it coagulates litmus milk rapidly, decolorizing the litmus and then digesting 
the milk clot with the reaction alkaline, and lastly that it produced two pigments in 
its growth, — a non-specific fluorescent pigment and a specific bluish-green pigment 
called " pyocyanin." 

This is a very common organism, occurring often in the intestine, and on the 
skin, especially in the folds of the axillae and groin. It is the pyogenic bacillus 
which produces blue pus. It is the organism of some cases of septicaemia of 
children, but its most important role, as a pathogenic organism, is as the cause of 
cystitis and ascending genito-urinary infections. 

Bacillus Aerogenes Capsulatus— This is one of the most widely distributed 



THE URINE: BACTERIA 



291 



organisms known. It is a constant inhabitant of the intestine of men and animals, 
and is common in the soil, water, milk, etc. 

This is a large bacillus, from 1.5 to 6 At long and 1 thick. It is non-motile, 
capsulated, and produces spores in the animal body and when grown on blood 
serum. It stains easily in all the ordinary stains and does not decolorize by Gram's 
method. 

Bacillus aerogenes capsulatus is a pure anaerobe, growing only in the complete 
absence of oxygen. It grows best (under anaerobic conditions) at 37 0 C. in the 
depth of solid media as grayish- white or brownish colonies with fine feathery or 
hair-like projections from the edges of the colonies. It ferments sugars easily. 
Litmus milk is coagulated, decolorized, and the clot later digested. 

Since it occurs very often in mixed infections the best way to cultivate it is 
to heat the specimen containing the mixture of organisms at 8o° C. for a few 
minutes to kill off all but spores. Then plates are made which are cultivated 
anaerobically. (The most of organisms in a mixture are not spore producers, and 
so after the heating but few forms will be left alive from which to select this 
bacillus.) 

A still better way is to inoculate a rabbit intravenously with the material 
containing the mixture of organisms. After five minutes the animal is killed and 
placed in the thermostat for 6 or 8 hours or left in a room temperature for 18 to 24 
hours. The animal will become much distended with gas. Bacillus aerogenes 
capsulatus can now be obtained in almost pure culture from the blood. 

This organism is one of the most important of the pathogenic bacteria, and 
is yearly assuming greater importance. Infections with this organism are extremely 
grave. Those of the genito-urinary tract occur not infrequently as the result of 
dirty technic in obstetrics. 

Bacillus Tetani. — The tetanus bacillus is a slender organism about 4 or 5 fi 
long and 0.5 & thick. It is a motile bacillus and has a great many very long slender 
flagella. It is a spore producing bacillus and since the spores have a diameter 
three or four times that of the bacillus and are usually situated at the end of the 
bacillus the shape of the sporulated organism is characteristic, resembling a drum- 
stick. Sometimes there will be a spore at each end and the result is a dumb-bell 
form. These spores are very resistant to heat, and are not killed by a temperature 
of 8o° C. for one hour. 

This bacillus stains well in all the ordinary bacterial stains, the body of the 
bacillus taking an unusually uniform stain. It is not decolorized by Gram's 
method. 

The tetanus bacillus is a perfect anaerobe (grows only in the absence of 
oxygen) and can be isolated only with extreme difficulty. Fortunately it is not 
necessary to grow it since its appearance in smears is characteristic. 

This organism is one of the most ubiquitous and important of pathogenic 
organisms. Its normal habitat seems to be the intestine of cattle and so it is 
widespread wherever is contamination with manure. 

Staphylococcus Pyogenes Aureus. (Micrococcus aureus.) — This organism is a 
coccus which occurs in groups, hence the name " staphylococcus." When actively 
growing it may occur singly or as diplococci. The individual organisms are spheres 
a little less than 1 micron in diameter. It stains well in all aniline dyes and is 
not decolorized by Gram's method. It is not a flagellated coccus. It grows well 
in all ordinary media. If grown directly from the animal body its colonies will 
sooner or later develop a golden yellow pigment, seen first at the edges of the 
thick, glistening, dull white growth, and later spreading throughout the whole 
growth. The most pigment is produced on potato. This organism liquefies gelatin, 
produces acid in milk, and ferments with gas production nearly all sugars. It is 
pathogenic to animals, producing either a fatal septicaemia, or, if the animal survives 
for a few days, a pyaemia with multiple abscess formation. In man it is the com- 
mon pus producing organism. It especially produces local pus foci ; as boils, 
abscesses, etc. 

Staphylococcus pyogenes albus is also one of the most important pyogenic 



292 



CLINICAL DIAGNOSIS 



organism. It differs from Staphylococcus pyogenes aureus only in that no yellow 
pigment is produced. Many think that it is really a variant strain of aureus. 

Staphylococcus epidermidis albus is a normal inhabitant of the deep layers of the 
skin. It is quite similar to Staphylococcus pyogenes albus, but is less pathogenic 
and a feebler grower. 

Streptococcus Pyogenes. — This organism is a coccus about i A 1 in diameter 
which occurs in chains of from two to one hundred or more. The members of 
the chain are slightly flattened against each other. It is not a capsulated strepto- 
coccus as are the chain forms of Diplococcus lanceolatus and as is Streptococcus 









! 1 s/ 3 

y v . 




% ' . 


W ■ : ; " : V; '" " ' ' 

P .,„.■. V 


f 


# 

■ .... ' I 


' it* 








i t 





Fig. 54a. — Micrococcus aureus. Photomicrograph by Dr. Thomas M. Wright. 

mucosus. It does not decolorize by Gram's method. It grows on all ordinary 
media, but is a feeble grower, and its colonies are so minute and translucent 
that they are easily overlooked. Also this organism is quickly overgrown in mixed 
cultures. That there are several varieties of streptococci none will deny, but 
observers cannot agree on any manner of division of the groups. Some strains of 
streptococci do not grow at all at room temperature ; some coagulate milk, others 
do not ; some grow on gelatin, which they do not liquefy, others do not ; all are 
quickly killed off in acid-reacting media, and all decolorize litmus milk. 





















I 

* . r 

" i 





Fig. 54b. — Streptococcus pyogenes. Photomicrograph by Dr. Thomas M. Wright. 

In the search for this organism in the urine, sputum, pus, etc., bacterioscopy 
of the exudate is of far more value than cultural methods. 

Streptococcus pyogenes is an intensely pathogenic organism in man, producing 
rapidly spreading inflammations with much necrosis, but with little pus production. 
It is especially prone to cause inflammations of the serous membranes. It is an 
important cause of septicaemia and pyaemia. It is the most widely spread of all 
pathogenic organisms. 

The bacteriological study of the urine is often important in 
septicaemia, perhaps in acute nephritis due to infection of the renal 



THE URINE : BACTEPJA 



293 



cortex, certainly in pyelitis, ureteritis, cystitis, prostatitis and urethritis. 

In cases of Septicemia one seldom searches for the organism in 
the urine, since blood cultures are much more satisfactory. But since 
the importance of typhoid bacilluria in the spread of that disease 
has been recognized, the presence of this organism in the urine has 
aroused a new interest. It is now known that Bacillus typhosus can 
be found in the urine of about one-third of the cases of typhoid fever 
during the attack. Sometimes they are few in number, sometimes so 
many that the urine is clouded by them alone and shimmers when 
shaken as does a bouillon culture. Even five hundred million of these 
bacilli may be found in one cubic centimetre of the fresh urine. While 
as a rule this bacillus clears up with the fever, yet in certain cases it 
may persist for years, and few or no local symptoms warn these 
" chronic bacillus carriers " that they are spreading an epidemic of 
typhoid fever far and wide. It is because of this bacilluria that all 
typhoid patients are now given urotropin during their convalescence. 
These organisms must have come from the blood originally, but that 
they later multiply in the pelvis of the kidney seems most reasonable. 

In other forms of septicaemia the invading organism is often found 
in the urine. The occurrence in the urine of Bacillus tuberculosis in 
cases of chronic tuberculosis and especially of the acute miliary form 
has already been mentioned. In a recent case of streptococcus menin- 
gitis secondary to otitis media and mastoiditis, the fresh urine on the 
day of death attracted attention because it was so cloudy. Micro- 
scopical examination showed that the turbidity was due entirely to 
chains of streptococci. 

That the bacteriology of the urine in acute infectious diseases will 
assume greater and greater importance there can be little doubt. It 
was the opinion some years ago that in acute infectious diseases the 
kidneys " excreted " the organisms, but animal experiments did not 
bear out this opinion, and so for a few years they were supposed to 
be killed and disposed of by the tissues. Now the question again 
assumes importance, since in typhoid fever at least the output of the 
bacilli in the urine is something enormous. 

Infectious Nephritis. — So many cases of acute nephritis date 
to an acute infectious disease, such as pneumonia, tonsillitis, influenza, 
typhoid fever etc. (to say nothing of scarlet fever, measles, etc., dis- 
eases the specific organisms of which are not known) or to an acute 
infection, as in a recent case of streptococcus infection of the arm with, 
acute nephritis developing while under observation, that it would not 
be unreasonable to think that the complicating acute nephritis might 
be due to the same organisms that cause the primary infection, and! 
that cultures from the urine of these cases might lead to interesting 
results. The same may be true of the so-called " febrile " albuminuria. 



294 



CLINICAL DIAGNOSIS 



The interesting cases of unilateral nephritis certainly suggest a local 
infection of the renal cortex, and, clinically, there is a group of chronic 
nephritis cases which run a quite different course from the usual 
(see page 318). This subject has received very little attention. 

Acute pyelitis is practically always an infection. Fortunately 
now it is an easy matter, thanks to the gynecologists and genito- 
urinary surgeons, to catheterize the ureters of women and men, and 
so to get cultures directly from the pelvis of each kidney. Acute 
pyelitis may be due to a primary infection of a normal kidney by 
organisms in the blood, or to an infection secondary to the irritation 
of a stone, e.g., to an ascending infection. In a pyuria of renal 
origin it is often easy to cultivate the infecting organisms. If the 
urine cultures are sterile, the cases are usually of tuberculosis of the 
kidney. We will speak of the bacteriological findings in pyelitis in 
connection with those in cystitis. 

It may be mentioned here that pyelitis without localizing symp- 
toms is quite common, and that a pyelitis may continue for considerable 
time before a cystitis begins. 

Cystitis. — Among the cases of cystitis those due to tuberculosis 
form so well defined a group that they are here described separately. 

Tuberculous Cystitis. — A primary tuberculous cystitis is a very 
rare condition. The disease usually descends from the kidney, but in 
men may also ascend from the genital tract. The diagnosis of the 
descending cases especially is of great importance, since the symptoms 
are usually vesical, and the renal disease even though of extreme 
grade may pass unnoticed both by patient and doctor. The question 
of renal tuberculosis can best be decided by cystoscopic examination, 
and, if necessary, ureteral catheterization, which will decide the source 
of the pus. In the following pages we include under the urinary 
findings of cystitis those which the kidneys contribute. 

Cystitis is an inflammation of the bladder due to some infecting 
organism. The normal bladder is very resistant, and therefore hard 
to infect. Organisms introduced are quickly gotten rid of, and seldom 
set up an inflammation. This resistance to infection seems explained 
by the nature of the bladder's epithelial lining. Most organisms can 
gain foothold there only after some predisposing factor has lowered 
the resistance of the bladder wall. Among these conditions favoring 
infection may be mentioned, the irritation from a calculus ; a posterior 
gonorrhceal ureteritis; and especially the retention of urine from any 
cause, such as childbirth, enlarged prostate, urethral stricture, spinal 
cord disease, and prolonged narcosis. If to these conditions be added 
frequent catheterizations the chances of a cystitis are excellent. There 
is another origin of infection which just now is attracting considerable 
attention; we refer to a direct extension from the rectum. Animal 



THE UEINE: BACTEKIA 



295 



experiments would suggest that disease or injury of the rectal mucosa 
is an important element in this infection. There are two organisms 
which seem exceptions to the above rule that the resistance of the 
bladder wall must first be considerably lowered, — i.e., the tubercle 
bacillus, and the proteus. The latter organism if introduced into a 
normal bladder will set up a cystitis. 

Tuberculous cystitis occurs especially in young patients. It begins 
insidiously, and lasts for years. There is usually increased frequency 
of micturition, but not always. The urine is acid; there is a variable 
amount of, and often considerable, pus present, and cultures made 
from the urine are negative. The pyuria may have escaped the patient's 
attention and the condition be accidentally discovered. There are 
two general rules. All persistent, acid pyurias in the young are pre- 
sumably tuberculous until the contrary is proven (Kelly) ; and all 
sterile pyurias are of either tuberculous or gonorrhceal origin. The 
tubercle bacilli should be looked for and usually will be found (see 
page 286). It is easier to demonstrate the tubercle bacillus in tuber- 
culous cases than the gonococcus in the gonorrhceal. 

There is another interesting group of very early cases of tuber- 
culous cystitis in which practically no pus is present in the urine. 
There is slightly increased frequency of micturition, and hsematuria. 
The hematuria is slight and transitory. It may persist for a few 
days and then not reappear until after an interval of weeks. The 
urine is clear, rather highly colored, but with the last of the voiding 
are usually seen a few drops of blood. 

In advanced cases of tuberculous cystitis the urine remains acid, 
there is often much pus, tubercle bacilli are easy to demonstrate, and 
there is persistent or recurring hematuria. Following a secondary 
infection, and this is sooner or later quite certain to follow, the pus 
usually increases and the urine often becomes alkaline. 

It is important to remember that cases of tuberculous prostatitis and 
ureteritis may so resemble tuberculous cystitis that only a cystoscopy 
examination will decide the question. 

Cystitis due to Organisms other than Bacillus Tuberculosis. — 
Among the organisms found are Bacillus coli communis, Staphy- 
lococcus pyogenes aureus, Staphylococcus pyogenes albus, Streptococ- 
cus pyogenes, Bacillus proteus vulgaris, Bacillus pyocyaneus. Bacillus 
typhosus, Bacillus lactis aerogenes, and others. In many cases it is 
difficult to determine just how important in the etiology of the cystitis 
the organism found is. 

Many organisms found are certainly harmless saprophytes. 

Bacillus coli communis is the commonest invading organism. This 
sets up a very chronic cystitis. 



296 



CLINICAL DIAGNOSIS 



The gonococcus can with great difficulty get a foothold in the 
bladder, for in all the very numerous cases of gonorrhceal posterior 
urethritis the organism must enter the bladder. The wall at the trigone 
seems the most susceptible spot in the bladder. A definite cystitis 
may develop as part of an acute urethritis and clears up rapidly, unless 
we include most of the cases of acute trigonitis. The gonorrhceal and 
tuberculous types are the two which seem exceptions to the rule that 
pyuria is an almost invariable symptom of cystitis. It is very difficult 
indeed to demonstrate the gonococcus in cystitis. Secondary pyogenic 
infections superimposed on a gonorrhceal cystitis are a not uncommon 
sequel of this condition. 

Proteus cystitis is a common and very distressing form. This 
seems almost the only organism which when introduced into a normal 
bladder will set up a cystitis (Melchior) . The urine in these cases is 
very alkaline, and the abundant pus is transformed into a ropy, sticky, 
mucoid material. 

The streptococcus cystitis is often a very severe form, but some- 
times is mild. Bacillus lactis aerogenes is said to be a much commoner 
cause of cystitis than the figures would lead one to expect. 

The catheterized urine in cystitis practically always contains pus. 
Certain cases of tuberculosis and of gonorrhoea are possible exceptions 
to this rule. As already mentioned, the source of much of this pus 
may be the kidney. When there is fever a pyelitis should be suspected; 
also when there is more albumin than the pus alone could explain. 
The pus varies greatly in amount. As a rule the most of the pus 
appears in the first glass, and least in the second glass of the three- 
glass test. This holds true only if the patient has been resting before 
voiding. The condition of the pus cells will depend on the reaction 
of the urine. When this is acid, the pus cells are well preserved, some- 
times amoeboid, and settle as a granular layer on the bottom of the 
glass. When very alkaline, as in proteus cystitis, not one pus cell may 
be seen. The pus is transformed into a sticky, ropy, mucoid substance. 

The reaction of the urine in the tuberculous cases is usually acid 
until secondary infection by proteus or the streptococcus occurs. In 
chronic cystitis due to the colon bacillus and Staphylococcus albus and 
other organisms with slight virulence the urine may be acid or alkaline. 
When the urine is alkaline the phosphates are precipitated, the pus 
cells transformed and the odor becomes alkaline and foul. 

Red blood cells are numerous in the urine of cases of acute cystitis 
and vary in number with the acuteness of the attack. They are uni- 
formly mixed with the urine. The haemorrhages from the bladder 
wall are slight. The larger haemorrhages come from the kidney, from 
vesical tumors, or especially from the prostatic urethra. In the 
posterior urethritis cases blood may continuously ooze back into the 



THE TJKENTE: BACTEEIA 



297 



bladder and the voiding of bloody urine be followed often by a little 
pure blood. 

For mention of the epithelial cells, see page 265. 

In " membranous," " exfoliative," " croupous," " diphtheritic," or 
" desquamative " cystitis the patient passes flakes, or masses, or moulds 
of a tough fibrinous membrane containing much degenerated epithe- 
lium. These are supposed to be clue to necrosis of the inner layers of 
the bladder wall. In gangrenous cystitis fragments of the epithelial 
and muscular coats of the bladder are expelled in the urine. In hem- 
orrhagic cystitis there may be much bloody infiltration of the bladder 
wall. It might be mentioned that one sees clinically these severe forms 
very seldom. They occur especially after traumatic or operative open- 
ing of the bladder and are usually terminal events. 

An interesting problem for the clinical laboratory workers to 
decide is how well justified is the statement, frequently heard, that 
changes in the reaction, the specific gravity, and the amounts of normal 
constituents of the urine are important in lowering the resistance of 
the wall of the bladder to infection. 

Bacteriuria. — By bacteriuria is meant the presence in the urine 
when voided of so> many organisms that they cloud the urine. We 
mention this subject here since there is usually a mild cystitis or later 
there will be, and since the urinary features indicate such a condition. 
Indeed the symptoms may indicate a severe cystitis and yet cystoscopic 
examination show the bladder normal. 

A transitory bacteriuria often follows massage of the prostate 
gland. It begins within a few, hours after this procedure and may 
last one or two days. There are no symptoms. The organisms are 
supposed to* come originally from the rectum. 

The cases of persistent bacteriuria? fall into two* groups. The first 
of these is of renal origin, and has been already mentioned on page 
293. The organisms in these cases are usually either the typhoid or 
the colon bacilli. The second group includes the cases secondary to 
a posterior urethritis and prostatitis. The foci of infection is in these 
organs, but the organisms grow in the bladder. They are so numerous 
that the urine is very cloudy. Very little pus is present. 

In gonococcus, typhoid, and colon bacteriuria the urine remains 
acid. In streptococcus and staphylococcus bacteriuria the reaction 
may be acid, neutral, or alkaline. The staphylococcus albus bacteriu- 
ria, however, is usually associated with alkaline urine. 

INFECTIONS OF TFIE URETHRA AND EXTERNAL GENITAL ORGANS 

In this connection it will be necessary to describe three very impor- 
tant organisms not mentioned in the preceding pages. 



298 



CLIXICAL DIAGNOSIS 



The Gonococcus. — The gonococcus is an organism deserving special mention. 
Every clinical laboratory worker should be skilled in its recognition. Formerly sup- 
posed to be the cause of unimportant, transitory, local infections, it is now known 
to be one of the most important of organisms. 

The gonococcus (see Fig. 54c) is a coccus about 1 M in diameter, which 
occurs, as a rule, in pairs. The adjacent edges of these diplococci are flattened, 
giving the organism the well known biscuit shape. In smears of gonorrhceal pus 
it is found chiefly inside pus and epithelial cells, or in masses on their surface: 
but some are found free. It stains well in all the ordinary bacterial stains, but 
especially in methylene blue, and discolorizes by Gram's method. (This organism 
in smears of pus, however, decolorizes so slowly that it may be necessary to leave 
the specimen in alcohol for ten minutes.) It grows only on media containing some 
albuminous constituent of the human body. For its recognition it is necessary to 
show that it occurs as biscuit-shaped diplococci, in clusters or clumps, some of 
them at least intracellular, that it decolorizes by Gram's method, and that it grows 
only on the above mentioned media. Blood agar and blood serum are excellent 
media, but agar mixed with ascitic fluid or hydrocele fluid is good, or a medium 
made up of urine, blood serum and agar. Its growth on proper media is a thin 
moist homogeneous layer which dies out in a few days. Cultivated under the best 




Fig. 54c. — The Gonococcus. A smear of pus from the urethra. Photomicrograph by 
Dr. Thomas M. Wright. 



conditions and transplanted frequently, the gonococcus will survive but for a few 
generations. It is very susceptible to changes in temperature. It dies in a few 
hours in pus at room temperature, and is quickly killed by a temperature of 40 0 or 
41 0 C. It is killed rapidly by drying. 

The gonococcus is the important causative agent for urethritis and periurethri- 
tis, prostatitis, and infection of the connecting ducts and glands of the genito-urinary 
system, the seminal vesicle, prostate, epididymis, bladder, Bartholin's glands, vagina, 
uterus, tubes, etc. ; it causes an eczematous skin eruption about the genitals ; it is 
an important cause of proctitis, peritonitis, meningitis, endocarditis, and especially 
of conjunctivitis, arthritis, and septicaemia. In all these conditions the clinical 
laboratory worker must be on the lookout for the gonococcus. One should not 
demand a discharge as a necessary indication of possible gonorrhceal infection, for 
it may be found where little pus is present, as in the vaginal discharge of infants, 
and the fluid from the joints with chronic arthritis. 

Much has been written of the organisms often found in the normal urethra 
which morphologically cannot be told from the gonococcus, and which also 
decolorize by Gram's method. While these will grow easily on ordinary media this 
method of differentiation is seldom used since the point of importance is that the 
pseudo-gonococcus never occurs in large numbers. For the recognition of the 
gonococcus it is necessary to find groups or clumps of these organisms in a smear, 
not only one or two on a side. 



THE URINE: BACTERIA 299 

Acute Anterior Urethritis. — The discharge from a case of 
acute urethritis, very early in the case (that is, for the first few hours), 
is scanty, of the color of water and milk, or starch solution, and con- 
sists chiefly of serum and epithelial cells, very few leucocytes, often 
some red blood cells, and a few gonococci, chiefly extracellular. 
After a few hours, however, the discharge becomes abundant, yellow 
in color, creamy in consistency, and composed of almost pure pus, and 
often some blood. Gonococci are easily found. During the first very 
few days it is interesting that the gonococcus is the only organism 
found. After this the ordinary rich urethral flora returns. 

In an untreated case, which may recover spontaneously after from 
four to six weeks, the discharge becomes again starchy, more and 
more scanty, and consists of abundant mucus, and fewer pus cells. 
The epithelial cells are more numerous and the gonococci become 
fewer and fewer. It may take repeated searches to find the organism. 
Finally there is a discharge of almost pure mucus which often greatly 
distresses the patient. It contains no pus or gonococci. In case the 
disease had not extended beyond the anterior urethra the patient is 
now well. But only too often the infection travels from the anterior 
to the posterior urethra, and to the adjacent structures. Also sec- 
ondary infections by pyogenic organisms are common, and these 
modify the exudates much. 

In posterior urethritis the discharge is often profuse, but, restrained 
by the compressor urethra? muscle, it all flows back into the bladder, 
and is voided with the urine. The discharge from the anterior urethra 
at this time may be very scanty. If the patient pass his urine in two 
portions, the discharge from both posterior and anterior urethra will 
be washed out with the first portion of urine, and if the amount of 
exudate from the posterior portion be small, the second specimen of 
urine may be clear. But usually the second glass also will contain pus, 
since the exudate has been flowing back into the bladder, yet it should 
not contain as much as the first glass. If the anterior urethra is well 
irrigated with boric acid solution and then the patient voids into two 
glasses, the presence of pus in the first will indicate a posterior ureth- 
ritis. The best time to try this test is with the first voiding in the 
morning. 

The sequelae of posterior urethritis are prostatitis, vesiculitis, epi- 
didymitis, and cystitis. In very acute posterior urethritis the frequent 
and excessively painful micturitions are very distressing symptoms. 
There is often a terminal hematuria. The whole urine may be bloody 
from the blood which constantly flows back into the bladder, but at the 
end of micturition a few drops or more of pure blood often flow from 
the urethra. 

If a chronic urethritis follows, the discharge may be continuous 



300 



CLINICAL DIAGNOSIS 



and fairly profuse or very scanty. In the latter case there is perhaps 
only enough to glue together the lips of the urethral orifice, or a little 
glairy fluid consisting of shreds of mucus enclosing a few pus, but 
more epithelial, cells. This discharge should be carefully distinguished 
from the glairy discharge following an acute urethritis. Smears 
should be carefully studied for pus cells and gonococci. This exudate 
is washed out of the urethra as Tripperfaden (see page 277). It is 
very difficult to demonstrate the gonococcus in them. 

These " clap threads " when long, translucent, and branching are 
made up mainly of mucous which is " rolled up " from folds in the 
urethral mucosa ; when short, thick, tack-shaped and sinking quickly to 
the bottom of the glass, they contain considerable pus and are supposed 
to come from the urethral crypts. Some of the shreds from the pos- 
terior urethra are short, slender, delicate, and comma-shaped. These 
are from the prostatic excretory ducts (Fiirbinger's books). These 
shreds should be carefully examined for gonococci. 

When abundant, the discharge may be a thick pus, in which case 
pyogenic organisms may also be present but this is not always the 
case, or muco-pus, or almost pure mucus. The flow is very inter- 
mittent. 

If the patient voids into three glasses immediately after irrigating 
the anterior urethra and shreds are found in any of the glasses there 
is surely a chronic posterior urethritis. In these cases the whole volume 
of urine is often slightly cloudy, since the exudate is constantly flow- 
ing back into the bladder. 

In women an acute anterior urethritis is of briefer duration and 
less apt to become chronic than in men. ( Many deny this last point.) 
Next to the urethra, the cervix is the most common focus of infec- 
tion. The discharge is at first slimy and blood-stained, and later a 
milky pus. In this location, especially, is the infection apt to become 
latent and chronic, and the only sign a viscid catarrhal mucous 
discharge. 

The discharge in cases of vulvitis and vaginitis is often a profuse 
and very fetid pus, since so often there is a mixed infection. 

Xon-specific Urethritis. — An urethritis due not to the gono- 
coccus but to various other organisms, the colon bacillus, the diph- 
theria bacillus, streptococci, staphylococci, etc., does occur. 

Smears from the exudate will show the presence of these organ- 
isms in great numbers, but it is well to remember the frequency with 
which secondarv infections complicate gonorrhoea and the difficulty 
one often has to find the gonococcus in gonorrhceal cases. 

In these non-specific cases the exudate is pus, but the discharge is 
not profuse, the case is mild and responds readily to treatment. 

Bacteriorrhcea. — This name is given to the condition charac- 



THE UKINE: BACTEBIA 



301 



terized by a discharge from the urethra of a thin opaque fluid which 
microscopically consists almost entirely of mucus and saprophytic 
bacteria of all varieties. No pus cells are present in the discharge. 
There are no other symptoms. The condition clears up quickly under 
treatment. 

Prostatitis. — Prostatitis may be due to the extension of an infec- 
tion from the urethra or from the rectum, or an infection by organisms 
from the blood stream. 

The diagnosis of acute prostatitis is more a matter of physical than 
urinary examination. In chronic prostatitis* the diagnosis is made by 
physical examination but also by the examination of the prostatic fluid 
which one obtains by massaging the prostate gland after the urethra 
has been well irrigated. 

The normal prostatic fluid has been described on page 306. The 
fluid in a case of chronic prostatitis may contain some or all of the 
normal constituents in varying amounts, or none of these. No diag- 
nostic or prognostic value can as yet be ascribed to the presence or 
amounts of these normal constituents. The abnormal element of 
greatest importance is pus. In some cases at times, and especially at 
the first examination, no pus cells will be found, and later many. The 
amount of pus bears a fairly direct relation to the extent of prostatic 
involvement. Red cells are sometimes abundant. Spermatozoa, 
active or immobile, are found in varying numbers. 

When there is so much prostatic fluid that a discharge follows 
urination or defecation the condition is called " prostatorrhcea " (also 
called "spermatorrhoea"). This usually indicates also a mild 
prostatitis. 

The prostatic fluid is a thin, bluish skim-xnilk-like fluid, which in 
prostatitis is modified by the presence of pus. In chronic prostatitis 
the fluid is always alkaline to litmus. 

The fluid which can be expressed from the seminal vesicles is thick 
and gelatinous, resembling boiled tapioca or sago. This fluid sinks 
in the urine. Its chief constituents are " mucin globules," large 
unformed masses resembling large non-nucleated epithelial cells (Fig. 
60, b)j spermatozoa (Fig. 61 represents a large mucin globule full of 
spermatozoa), pigmented epithelial cells, and small finely and coarsely 
granular non-nucleated epithelial cells. 

Dr. Youngf has emphasized the value of the seven-glass test in 
the differential diagnosis of chronic inflammatory lesions of the 
urethra, prostate, seminal vesicles, and bladder. The patient com- 
presses the urethra far back at the root of the penis (at the suspensory 

* For complete description see Young, Johns Hopkins Hosp. Reports, 1906, 
vol. xiii, page 302. 

t Johns Hopkins Hosp. Rep., 1906, vol. xiii., page 1. 



302 



CLIXICAL DIAGNOSIS 



ligament) while the anterior urethra is irrigated by means of a long 
irrigating tube. The fluid is caught in two glasses. The first, I 1 , will 
contain the shreds, if any are present, the second, I 2 , should be per- 
fectly clear. The patient's fingers are then removed and the tube 
carried back as far as the deeper part of the bulbous urethra. The 
washing is again caught in two glasses. The first, I 3 , will contain 
the shreds from the bulbous urethra (if any are there), the second, I 4 , 
should be clear. The urine is then voided into three glasses, F, I 6 , I 7 . 

I 5 , P and I 7 all will contain bladder urine, and mixed uniformly in 
each the exudate of posterior urethritis which has flowed back into the 
bladder between voidings. In addition to this 

1 5 will contain the exudate in the posterior urethra which will 
usually be washed clean by the flow of urine, 

1 6 may contain the last traces from the posterior urethra, and 

. I 7 will contain also urine from the most dependent portions of the 
bladder, also the contents of the prostatic and ejaculatory ducts which 
often do not discharge the exudate collecting in them until the mus- 
cular contraction made at the end of micturition forces out the 
plugs of thickened exudate which occlude their mouths (Furbinger's 
hooks). 

BACTERIOLOGY OF THE EXTERNAL GENITALIA 

Bacillus Ulceris Caxcrosi ( Ducrey's Bacillus). — This organ- 
ism is now recognized as the cause of soft chancre. It is found in 
smears of the purulent discharge from these sores, but always mixed 
with a host of other organisms. (Sections of the tissue show it in 
pure culture.) 

This bacillus is a small oval rod about 1.5 fi long and 0.5 fi thick, 
which stains readily in all bacterial stains, but decolorizes very easily. 
It is a very poor grower indeed, but some claim it can be cultivated 
on blood agar. 

Trepanoma Pallida, Spirochete Pallidum. — This organism 
( see Fig. 54d) is a spirochete, the average length of which is from 
4 to to /x (although some are even 20 m long), and thickness 0.5 fi 
or less. It is tightly twisted like a cork-screw in 3 to 26 regular 
curves, and the fineness of the curves is a characteristic feature. It is 
pointed at each end. It is a flagellated organism, but shows only a 
twisting, rotating, or bending motion. They are usually found singly, 
although sometimes several are tangled. 

To obtain this organism from a chancre, the sore is first well 
cleaned with soap and water, rinsed, and dried. This removes the 
majority of Spirochaete refringens. The chancre is then lightly 
curetted, the blood wiped off, and the sore squeezed until a drop of 
blood stained serum exudes. A thin smear preparation is then made. 



THE URINE : BACTERIA 



303 



Enlarged glands may be examined by aspirating a drop of serum 
from them with a hypodermic syringe. Smears may be made from 
the skin rashes by removing the superficial layer of epidermis and 
squeezing a minute drop of serum from the papule. In the case of 
the blood, i cc. of blood is mixed with 10 cc. of 0.3 per cent, acetic 
acid, centrifugalized, and thin smears made from the sediment. 

This organism stains very badly, so great care must be taken with 
the technic. The smear is fixed by simple air drying, or by holding 
it for a few seconds over the mouth of a bottle containing crystals of 
osmic acid. 

One of the best stains is Giemsa's azur-eosin mixture : 

Eosin solution (2.5 cc. of 1 per cent, eosin solution in 500 of water), 12 parts. 

Azur No. I (1 : 1000 in water), 3 parts. 

Azur No. II (0.8: 1000 solution in water), 3 parts. 

This stain must be used when freshly made up. The specimen is left 
in it for twenty-four hours. 



cR 


LI "". 








( L 



Fig. S4d. — On the left Trepanoma pallida (Spirochaete pallidum). A smear from a chancre. 
On the right Spirochsete refringens. A smear from a chancroid. 

The Giemsa mixture most in use is : 

Azur II, eosin, 3 gm. 
Azur II, 0.8 gm. 

Glycerin (Merck C. P.), 250 gm. 
Methyl alcohol (Kahlbaum I), 250 gm. 

(It is better to buy stains of this character than to make them.) 
To use this stain the specimen is dried in the air and then fixed for 
one hour in absolute alcohol and stained for twenty-four hours in a 
fresh dilution of the stain (1 drop of the above mixture to 1 cc. of 
distilled water). In this stain the organism takes a delicate violet 
purple color, and the nuclei of the leucocytes a deep blackish red. 
(The latter is the criterion for a smear well stained enough to justify 
the long search necessary to find the organisms.) 



304 



CLINICAL DIAGNOSIS 



MacNeal's stain is composed as follows : 

Methylene blue (crude), 0.25. 
Methylene blue (medically pure), 0.10. 
Eosin (yellowish), 0.20. 
Methyl alcohol (pure), 100. 

The specimen is heated on a cover glass in this stain for forty-five 
seconds. It is then moved about in sodium carbonate (1:20,000) 
solution for one or two minutes, washed in water and examined. The 
organism is stained a delicate blue or even black. 

Spirochete Refringens (see Fig. 54d). — This organism is 
often found with Spirochete pallidum. It is a common parasite, occur- 
ring in great numbers in many ulcerative lesions. It is larger, thicker, 
more refractile, its spirals are broader and more wavy, its ends are 
blunter, it occurs in greater numbers in a smear, and it stains more 
easily than Spirochete pallidum. 

On the skin about the genitalia is an abundant flora of organisms : 
streptococci, staphylococci (especially Staphylococcus albus), Bacillus 
coli communis, Bacillus pyocyaneus. Bacillus lactis aerogenes, Bacillus 
aerogenes capsulatus, and various strains of smegma bacilli. 

Vegetable Parasites. — See bacteriology of the urine, page 283. 

The yeast cells occur especially in diabetes, since they require a 
sugar medium. In this disease they may consume the sugar before the 
urine is voided and give rise to " pneumaturia." They also occur in 
alkaline urine and may form a sediment. To cultivate them the urine 
should be kept acid with acetic acid. 

Moulds may perhaps sometimes occur in the urine when voided, 
but the spores accumulate on standing. In a recent case of pyelitis, the 
pelvis of the kidney had been repeatedly irrigated through ureteral 
catheterization, on one occasion the urine which escaped was very 
bloody, and in it were found mycelial masses of some organism which 
would not grow on media. After washing the pelvis out well no more 
were found. They may have been introduced at a previous catheteri- 
zation. 

Sarci:nle smaller than those found in the gastric cases may also 
be found. 

Among the Animal Parasites which may be demonstrated either 
partly or entire in the urine are the hooklets, daughter cysts (even 
several hundred in a case), and fragments of membrane of echino- 
coccus cysts. There are no urinary symptoms of hydatid disease 
of the kidney unless there be catarrhal pyelitis or the cyst empties 
into the urinary tract. If the latter be the case the urine will appear 
watery, soapy, or bloody. Embryos of filaria are found in tropical 
hsematochyluria. (See page 642.) 

Flagellates belonging to the cercomonas or the trichomonas 
class occur. Concerning these there is a dispute as to their origin, 
whether present before voiding or a later contamination of the urine. 



THE URINE: PARASITES 



305 



Eustrongylus Gigas. — A few cases are reported, but in many 
they were mistaken diagnoses. In one case of chyluria these eggs 
were found. 100 (See Fig. 58a.) 




Fig. 55. — Sediment from echinococcus cyst. Above and to the left are two degenerated scolices 
(X about 60) ; to the right is the head of a scolex (X 400) ; below are hooklets of unusual shapes and a 
small mass of cholesterin crystals. X 400. 

SCHISTOSOMUM HAEMATOBIUM (BlLHARZ). f] 

Distoma Haematobium. — This worm, so com- ' 
mon in Africa, especially Egypt and the Trans- I 1 . 

vaal, has been found but six times in this conn- [ . 
try 101 and twice in Porto Rico (Martinez). 
The adult male (see Fig. 57) is 12 to 14 mm. 
long, flat, but so folded that it forms a gyneco- 
phoric canal which receives the female, which is 
20 mm. long and filiform. 

The adults live in the portal system and the 
mucosa of the urinary tract and rectum, also in 
the pelvis of the kidney. The results of its pres- 
ence are hemorrhages, " the Egyptian hsema- 
turia," either profuse or but a few drops at the 
end of voidings, pyelitis, even atrophy of the kid- 
ney. The eggs (Fig. 92) are voided and may 
become the nucleus of a stone. The symptoms are 
hsematuria with these eggs. They are large, — 0.16 
by 0.6 mm. in size, — with a transparent shell, and 
contain a ciliated embryo. 

Nematode worms other than filaria are sometimes found in the 



3&£ 



53 




Fig. 56.— A small frag- 
ment of echinococcus 
cryst-wall on cross frac- 
ture, showing transverse 
striation and pectination. 
X 50. 



160 Stuertz, Deutsches Arch. f. klin. Med., 1903, vol. lxxviii. p. 586. 
181 See O'Neil, Boston Med. and Surg. Jour., October 27, 1904, vol. cli. p. 453. 
20 



306 



CLINICAL DIAGNOSIS 



urine, some of which may be Anguillula aceti, or " vinegar eel." Stiles 
reports one case of infection of the bladder with this worm. Other 
cases may be due to contamination from the bottle in which the urine 
is collected. 162 These worms resemble closely Strongyloides in- 




Fig. 57. — Schistosomum haematobium, adult worms. (Copied from Braun.) 

testinalis, except that these worms (A. aceti) are slightly longer. 
(Males, 1.2 mm. long, 0.033 mm - wide; females, 1.9 mm. long, 0.06 
mm. wide; embryos, 0.25 to 0.3 mm. by 0.015 mm.) 

The student should always be able to recognize the various plant 
contaminations which occur in water and hence in vessels rinsed out 
with this water; that is, he should be able to say that they are 
plants and of no significance. A few of the most common we give 
in Fig. 58. 

Prostatic Fluid. — This fluid is best obtained by " milking" the pros- 
tate through the rectum. The urethra is first well washed, then the 

162 Billings and Miller, American Medicine, May 31, 1902. 



A % 

1 f\ \\ 1 



\\\ ' 



o 



Fig. 58. — Protophytes and other low forms of life often found in tap water. X 400. 



Fig. 58a. Eggs of Eustrongylus gigas. X 400. 



THE UEI^E: PAEASITEG 



307 



fluid expressed and collected. The amount varies greatly, from none 
to even 5 cc. of normal fluid at one milking. It is of a grayish-white, 
yellow, or greenish color, with a milky turbidity due to lecithin glob- 
ules, and of a characteristic odor. It is slightly viscid, tenacious, of 
light specific gravity since the solids are but 1 to 2 per cent., faintly 
alkaline as a rule, although it is acid to some reagents; its reaction 
varies very much, and is as yet a very uncertain quality. 

One examines first fresh for motile spermatozoa, then adds a drop 
of acetic acid to bring out the cells more clearly, and examines for pus- 
cells. (Fig. 59, b.) 

Microscopically, the most striking objects are the great numbers of 
lecithin globules (Fig. 59, a), which give it its milky appearance. 
These vary in size from those minute to others even half the size of a 



b 




Fig. 59.— Prostatic fluid. (X 400.) a, lecithin globules ; b, pus-cells ; c, epithelial cells ; d. corpora 
amylacea ; e, free granules from epithelial cells ; f , spermatozoa. 

red blood-cell. They are not very refractive, and can be easily distin- 
guished from fat. Their only significance is that an increase is a good 
sign in cases of chronic prostatitis. Corpora amylacea (Fig. 59, d; 
60, c) are often found, especially in advanced life, in which case they 
also appear in the urine. They are laminated, with a finely granular 
centre, often a nucleus. Of their composition nothing is known except 
that they stain blue with iodine ; they have no significance. Epithelial 
cells of various kinds are present. Some are large, polygonal, single or 
in groups, and of very varying size (see Figs. 59, c, 60, a) . Other cells, 
the so-called granular cells (Fig. 60, e), also of varying size, are simple 
masses of granules resembling fat, some of which resemble colostrum 
corpuscles. These break down, hence the refractive globules seen free 
in the fluid (Fig. 59, e) . Some granules resemble myelin (Fig. 60, d) . 
Columnar epithelial cells are sometimes present. In addition to these 
are large clear cells of very varying size, with or without nucleus (see 
Fig. 60, b), which are supposed also to be derived from the seminal 
vesicles. There are normally no pus-cells, nor any red blood-corpuscles. 



308 



CLINICAL DIAGNOSIS 



Spermatozoa (Fig. 59, f) are usually present. (For a description of 
these, see University of Pennsylvania Med. Bull., No. 3, 1902.) 

These should be examined fresh, to make sure of their motility; to study 
them more carefully smears are made, dried in the air, heated to 120°, and cooled 
slowly. The fluid should first be diluted with water even of twenty volumes in 
case much proteid be present. They are best stained in iron haematoxylin. The 
specimen fixed by heat is placed in 2 per cent, iron alum solution for from two 
to four hours, washed in water, then in 1 per cent, haematoxylin for twelve hours. 
They are decolorized with 1 per cent, iron alum carefully, and counterstained with 
saturated aqueous solution of eosin from one to three minutes, then dried and 
mounted. Many of them are abnormal in shape, some with two heads and with 
even three tails. These monsters seem never to move. 

One seldom tries to determine more than their presence and mo- 
tility; if motile, one is confident that they are functionally normal; if 
absent or non-motile, no conclusions are justified. 

In acute or chronic prostatitis many leucocytes are present, and 
lecithin is diminished. 

Spermin crystals resemble somewhat the Charcot-Leyden crystals, 
being colorless, transparent needles or whetstones, but are often imper- 
fectly crystallized. To demonstrate these the semen is allowed to 
stand. To the prostatic fluid, however, must be added one drop of 1 
per cent, ammonium phosphate and the specimen allowed to dry under 
a cover-glass for two hours. 

The prostatic casts which are said by some to resemble the 
urine casts markedly must certainly be rare, since we have asked those 
who have examined many hundreds of specimens, and they have never 
seen one. 

Tripperfaden. — These threads, which are seen grossly in the 
urine in cases of chronic gonorrhoea, are present as narrow delicate 
transparent mucous flocculi, which microscopically contain mucus and 
a few epithelial and still fewer pus-cells; this form is present in very 
chronic cases ; or shorter, firmer bands, in which the cellular elements, 
especially the pus-cells, predominate. They settle at once to the 
bottom of the glass, but are evident on agitating the urine, upon which 
the threads rise from the bottom. In an old urine they may be diffi- 
cult to demonstrate, since they have coalesced. 

Also short coma-like flocculi are seen which arise from the excre- 
tory ducts of various glands and follicles, and mean an intense in- 
volvement of the urethral glands. Those in the second glass are from 
the glands in the prostate, and are signs of chronic prostatitis. They 
consist of superimposed layers of cylindrical epithelium. 

Prostatic plugs are sometimes found which are large cylindrical 
masses of mucus. These are found in mild inflammations of the pros- 
tatic ducts. Other mucous masses are found full of spermatozoa 
(Fig. 61). 




C 

b 

Fig. 60. — Prostatic fluid, a, epithelial cells ; b, clear epithelial cells, from seminal vesicles(?); c, corpus 
amylaceum ; d, " granular cells " with droplets resembling myelin ; e, " granular cells " with fat droplets. 




Fig. 6oa.— Cells which resemble casts found in fluid massaged from a prostate, the seat of chronic 
prostatitis. (Kindness of Dr. George Walker, of Baltimore, who will later publish this and similar cases). 



THE UEINE 



309 



DISEASES OF THE KIDNEYS 

Albuminuria In order to get a general idea of the occurrence of 

albuminuria, the conditions in which it occurred most commonly, and, 
if possible, obtain some clue for further investigation in this important 
subject, we have abstracted the histories of 3631 hospital cases, taking 
them in order of admission to the hospital without reference to their 
diagnosis. Only such histories were abstracted the urine examinations 
in which appeared to us perfectly satisfactory. 

It very soon became evident that the age line, that is, the occur- 
rence of albumin in the various decades, is to be first determined. So 
important is this that the effect of any given agent or disease upon 




Fig. 61.— Mass of mucus filled with spermatozoa from urine catheterized at death. X 400. 

the kidneys can only be rightly determined in case the age be taken 
into consideration. 

We have divided the cases into three groups, — those in which 
the urine was throughout the stay in the hospital albumin- free ; those 
in which the albumin was present for a time but disappeared while 
under examination; and those in which albumin was present at each 
examination. As the age epochs we have chosen from one to fifteen, 
sixteen to twenty-five, twenty-six to thirty-five, thirty-six to forty-five, 
and so on through the epochs. The reason for choosing these figures is 
that the ages of fifteen and twenty-five are more truly transition points 
in a person's life than ten and twenty. Not only should the urine be 
studied by decades, but also the sexes should be studied separately for 
certain decades at least. On the whole, the sex has much less influence 
than one would expect. These figures will be published in full later. The 
neurasthenics may be taken as representing a group of normal men, 
for this diagnosis represents exclusion of other conditions. Of the 
men, the percentages with albumin-free urine were : one to fifteen years, 
100 per cent. ; sixteen to twenty-five, 87 per cent. ; twenty-six to 



310 



CLINICAL DIAGNOSIS 



thirty-five, 99 per cent. ; thirty-six to forty-five, 90 per cent. ; forty- 
six to fifty-five, 84 per cent. ; fifty-six to sixty-five, 70 per cent. ; sixty- 
six and over, 66 per cent. The drop at the period of adolescence is 
very interesting (see page 232). 

Of the fevers, typhoid after the twenty-fifth year is accompanied 
by a transitory albuminuria (febrile) in 30 per cent, of the cases, and 
a persistent albuminuria in about 30 per cent. One would expect 
this, since the fever is so continued and bacilluria is common (about 
one-third of all cases). Yet as a disease in the past history, typhoid 
fever strangely enough seems to have the least effect on the kidneys, 
notwithstanding that it has a deleterious influence on the peripheral 
blood-vessels. 

Malaria of the tertian and quartan types has little effect on the kid- 
ney, aestivo-autumnal much. Pneumonia has the highest percentage 
of transitory albuminuria of all the fevers we studied (but about 25 
per cent, of the cases are albumin-free), but almost no permanent 
effect. Pulmonary tuberculosis and acute articular rheumatism cause 
little febrile albuminuria. Of the afebrile diseases, the neuras- 
thenics are the best off ; the arteriosclerotics the worst. In fact, this 
disease, arteriosclerosis, seems the one dominating element among the 
causes of albuminuria. 

The relation between the anatomical lesions and urinary findings 
was studied. 

Cases with marked cloudy swelling at autopsy, but no other 
lesion, as a rule have had an albuminuria, usually slight, extending for 
two or three weeks before death. But in a few cases there was none 
even shortly before death. Casts are also present with albumin, usually 
hyaline, but also waxy, epithelial, and blood. 

Fatty kidneys (no other microscopical changes) are seen in 
various diseases, and have been divided into those with fatty infiltra- 
tion and fatty degeneration ; the former occurring in diabetes mellitus, 
pregnancy, etc., the latter in various infectious diseases, cachexias, 
anaemias, and following various poisons. 

The amount of urine is usually normal, although in some severe 
cases, decreased ; albumin is present in various amounts, a trace or 
much, and a relatively large number of casts, hyaline, granular, fatty, 
and epithelial ; with few or many red corpuscles. 

All of our cases examined had excreted albuminous urine before death, but 
in no case exceeding two weeks. Hyaline and granular casts were present. 

The urine of kidneys with chronic passive congestion is at first 
scanty, dark in color, very acid, the specific gravity between 1025 and 
1030. The urate sediment is often abundant. Urobilin and uro- 



THE UEINE: ALBUMIN UKIA 



311 



erythrin are increased and sometimes bilirubin is present. Sooner or 
later albumin appears in traces, later in good amount, even o.i per 
cent., and in one of our cases 0.6 per cent. Casts are present, chiefly 
hyaline, rarely granular. Yet here also on some days casts may be 
present in great numbers, hyaline, waxy, epithelial, and fatty. A 
very few leucocytes may be found and still fewer red cells. The 
points of importance in this urine are the small amount of albumin, 
the large urate sediment, the absence of renal epithelium, the scarcity 
of granular casts and leucocytes. The diagnosis of nephritis had 
been made in over half the cases. 

Acute Nephritis. — Acute nephritis has been divided into several 
groups, chiefly from the stand-point of pathology, but for the clinician 
a division is very difficult. Senator separates the tubular nephritis or 
acute parenchymatous from the acute diffuse. In the acute parenchy- 
matous the tubules especially are involved, and the glomeruli but little 
or not at all. The clinical symptoms are slight if any. The urine 
shows only a slight febrile albuminuria, a diminished amount of urine 
of rather high specific gravity, and few or no casts. From this form 
are all gradations to the acute diffuse nephritis. The urine contains 
often a heavy sediment, chiefly of renal epithelium, and hence the 
name " nephritis desquamativa." The epithelial cells may be single 
or in casts. Hyaline casts, few or many, are present. Crystals of 
uric acid and calcium oxalate are often present, red blood-corpuscles 
and haemoglobin in granular casts or masses. The leucocytes are 
usually few in number. The albumin is nearly always slight in 
amount, in remarkable contrast to the amount of sediment, and some 
claim that nearly all of it is nucleo-albumin from the cells. 

In the acute diffuse nephritis, a good illustration of which is that 
following scarlet fever, the clinical symptoms are much more severe. 
The urine is diminished in amount, there may, indeed, be anuria for 
the first twenty-four hours. From 50 to 100 cc. for the first day or so 
is not uncommon, but later from 200 to 500; specific gravity high, 
even 1030. Toward death there may be a diminished or an increased 
amount voided. The specific gravity was normal as a rule, 1015 to 
1017, but in some cases high, from 1023 to 1025 (when the urine was 
from 300 to 600 cc). It is usually of a dark color and cloudy. In 
very mild cases, however, it may appear normal. Blood is nearly 
always present. When slight in amount it imparts to the urine a slight 
smoky tinge, which may be recognized grossly. When larger in 
amount the urine may have a reddish-brown or a brownish or even a 
chocolate color, according to the proportion that is present between 
haemoglobin and methaemoglobin. Albumin is an almost constant fea- 
ture, and yet in some fatal cases there may be but traces, and these 
only on a few days, and alternating with periods of none, even till 



312 



CLINICAL DIAGNOSIS 



death. Serum albumin and serum globulin are present. If many cells 
are present in the sediment a certain amount of true nucleo-albumin 
may be expected. Albumose is also present, and in some cases is the 
only proteid found. The reason for this is not known. It may ex- 
plain, however, the cases described as albumin-free, the examiner 
using only a heat test, which did not precipitate the albumose. As a 
rule, the albumin is not above I per cent., and the globulin percentage 
is relatively high. In the sediment may always be found red blood- 
cells, mononuclear cells, few polynuclear leucocytes, and epithelial cells 
from the urinary tubules, which are present singly or in masses, and 
often very fatty. Among the crystals uric acid and calcium oxalate 
are found, and haemoglobin either in amorphous granules or in casts. 
In the hemorrhagic form of the disease in our series the red blood- 
cells were evidently remarkably few in number. The leucocytes were 
very abundant in one case of acute nephritis with multiple abscesses. 
Casts are present in varying numbers, and may be of any form ; epi- 
thelial, hyaline, and coarsely granular will predominate, blood and 
leucocyte casts may also be present. As a rule, the number runs par- 
allel to the amount of albumin, yet it varies greatly from day to day, 
and on some days may be enormous. In one case of acute hemorrhagic 
nephritis, with areas of complete necrosis, the amount of albumin was 
slight but large numbers of casts, leucocyte and granular, were 
present. In one case of general septicaemia the albumin occurred in 
but traces on certain days and was absent on others, and yet blood, 
hyaline, and leucocyte casts were found. 

During the course of an acute attack of nephritis the kidney shows 
every symptom of renal insufficiency. The nitrogen output is dimin- 
ished, not due to the diet alone. The chlorides and the phosphates 
are diminished, and hence the molecular concentration is less than nor- 
mal. The uric acid output is about normal, that of the xanthin bases 
is said to be increased. The ability of the kidney to form hippuric 
acid is diminished, and the glycosuria after phlorizin is either slight 
or absent. In mild cases and in severe ones as they improve the urine 
approaches normal. It is said that the albumin disappears last, but 
we believe the casts are often found later. 

Nephritis Haemoglobinurica. — In acute nephritis the amount of haemo- 
globin in the urine may be much, the number of red blood-cells few or 
none. In certain cases this is the cause of the nephritis, in others a 
symptom. The former is true in cases with blood destruction due to 
poisons, burns, etc. During infectious diseases the hemoglobinuria 
may be secondary, or both that and the nephritis due to the same cause. 
Such is found in typhoid fever, scarlet fever, malaria, Winckel's dis- 
ease of the new-born, and other conditions. This form of nephritis 
differs from pure haemoglobinuria by the greater amount of albumin 



THE UBINE: NEPHEITIS 



313 



and the richness of the sediment in casts, renal epithelial cells, leu- 
cocytes, and uric acid crystals. 

Acute Nephritis of Cholera. — This form is said to be a peculiar type 
of a pure parenchymatous, especially the tubular variety. The urine is 
diminished even to anuria for from five to seven days even. It is 
very rich in salts and may have a large urate sediment. Albumin is 
present in relatively larger amounts than in the other forms of paren- 
chymatous nephritis. The urine is dark and cloudy, but rarely bloody. 
Hyaline and granular casts are present, also' renal epithelium, red 
blood-cells, leucocytes, uric acid and calcium oxalate crystals. The 
urine is also characterized by its richness in the ethereal sulphates. 
Diacetic acid is often present and ammonia is increased. In one case 
after an anuria of fifteen days the person recovered. The condition 
of the urine improves much during the stage of reaction. 

The Nephritis syphilitica acuta praecox is sometimes marked by the 
immense amount of albumin present, in one case ( Hoffmann and Sal- 
kowski) 8.5 per cent. The urine coagulated solid. There was very 
little sediment, few casts, leucocytes, or blood-cells. 

Subacute Nephritis. Chronic Parenchymatous Nephritis. Chronic 
Diffuse, Non-Indurative Nephritis. Large White Kidney. — This form 
of subacute nephritis, which may follow an acute attack or develop 
without this, is characterized by its subacute course, for it is usually 
fatal within two years, and by the extreme oedema and the effusions in 
the serous sacs. It occurs especially in young persons who> work hard 
amid exposed, unhygienic surroundings. It may follow constitutional 
diseases, as tuberculosis, lues, or malaria ; also the use of alcohol. The 
diagnosis is usually easy from the history. 

The amount of urine is always diminished, the diminution vary- 
ing as the oedema, and especially at death. At the height of the dis- 
ease it varies from about 250 to 500 cc, as the case improves, how- 
ever, it increases, and if the patient be encouraged to drink he may 
void from 5 to 6 litres of a very dilute urine. The amount also is 
increased as the oedema or the effusions begin to absorb. The specific 
gravity, varying inversely as the amount, is, as a rule, almost normal 
or slightly increased, in some cases reaching 1040. The reaction is 
faintly acid, but in some cases alkaline even on voiding, and in all 
cases it quickly becomes so. This makes a search for casts difficult. 
The color is from a pale greenish-yellow to a reddish or a reddish- 
brown, cloudy as a rule from the large amount of sediment, and 
foaming easily on shaking because of the amount of albumin that is 
present. 

This is the form in which the albumin is very large in amount, both 
relatively and absolutely. The amount varies as the specific gravity, 
roughly, and seems to bear no relation to the oedema. It seldom 



314 



CLINICAL DIAGNOSIS 



reaches i per cent., although for months it may vary from 0.4 to 0.8 
per cent. In certain cases, however, it is greater. As the case 
changes to the chronic indurative form the amount of albumin be- 
comes less and less. Cases of 2 per cent, are rare, and Bartels has 
reported a case which varied from 4 to 6 per cent. The albumin 
quotient varies much. Nucleo-albumin is present in small amounts, 
also the albumoses. 

The urea is somewhat diminished, even when there is much dropsy. 
The uric acid varies somewhat less than the urea, and is excreted 
within normal limits. The ammonia is normal. There is a certain 
retention of chlorine and phosphoric acid. 

The sediments are much the same as in acute nephritis, but it is 
more common to find coarsely granular, fatty, and waxy casts. Red 
blood-cells may practically always be found, in especially large num- 
bers in the acute exacerbations. There is little difference between the 
urine of the white and the mottled kidneys except, perhaps, in the 
latter there are more red blood-corpuscles, leucocytes, and fatty cells. 

Functionally the kidneys are somewhat insufficient, and yet in the 
severe cases they do their work fairly well. This is thought to be 
due to the fact that the disease attacks certain successive parts of 
the kidney, and that while one part is inflamed the other parts can 
compensate. 

One would expect that a glomerular involvement would affect par- 
ticularly the amount of albumin, the tubular involvement especially the 
number of casts, and while in general this may be true, clinically it is 
of little importance, since the two anatomical conditions are always 
present and variations between them but slight. 

Except in young persons with a good past history, the diagnosis 
cannot be made without an autopsy, since an acute exacerbation of an 
unsuspected chronic case will show similar clinical features and very 
similar urine, yet at autopsy small contracted kidneys be found. 

Chronic Indurative Nephritis. — A subdivision of this form is ex- 
ceedingly difficult ; in fact, the size and color of the kidney are almost 
the only criteria, since all its histological elements are affected in nearly 
every case by degenerative, inflammatory, or regenerative processes. 
A somewhat related form of nephritis, " senile atrophy," is of almost 
physiological occurrence in every elderly person, the kidney becoming 
eld and therefore slighty sclerotic with the rest of the body. In fact, 
Dr. Osier emphasizes the point that in men above middle life the cortex 
is never perfectly normal — a few sclerotic glomeruli and a very 
slight increase of connective tissue may always be found. If the 
process, however, is simply sclerosis, there should be no urinary 
symptoms, and hence such cases are not suspected before the autopsy. 
As a result, however, of hard work, various diseases, gout, lues, and 



THE UKINE: NEPHRITIS 



315 



certain poisons, lead and alcohol, inflammatory processes develop. The 
result in such a kidney is the degeneration of the epithelial elements, 
and inflammation resulting in new growth of connective tissue which 
may be general or focal, subcortical or periglomerular. The kidney 
becomes hard and firm, diminishes in size, and is finally but a remnant 
of an organ. In some cases we find contracted kidneys at autopsy 
which could not possibly have been recognized from the urine. These 
show that a nephritis limited to foci can heal. In all such cases, how- 
ever, if it be the sclerotic process which predominates, there may be 
practically no urinary symptoms, and at autopsy kidneys of surpris- 
ingly small size may be found. Other cases are the result of a pre- 
ceding acute or subacute nephritis. 

The only classification which can be made, apart from the weight 
of the kidney and the thickness of its cortex, is in its color, and hence 
the division into the red and the white kidney, the red kidneys being 
the result particularly of arteriosclerosis as a primary factor. The 
red kidneys are large, firm, beefy, the sclerosis is considerable, and yet 
the size of the kidneys is seldom as much diminished as in the white 
form. In all cases it should be borne in mind that arteriosclerosis will 
be present, in some as the cause of the renal trouble, in others as the 
result. In a third group, both the renal and the arterial diseases are 
due to the same cause. The process may be local, one kidney affected 
more than the other. 

Chronic interstitial nephritis in its advanced forms is marked by 
its very insidious onset. Its only symptom may be a slight albu- 
minuria, and this may be absent for long periods. Later the albumin 
becomes permanent, casts appear, and later polyuria. The urine is 
increased slightly at first, but in a well-developed case from 2 to 3 
litres are voided daily, and rarely even as high as 12 litres. On the 
other hand, it may at times sink to normal or even under. It is pale, 
clear, definitely acid, and of a specific gravity which is constantly 
between 10 10 and 1005. This low specific gravity in a morning urine 
is always significant of this condition. The molecular concentration is 
diminished. The albumin seldom rises above 0.05 per cent., and 
usually is in mere traces. It is often absent in the morning voiding, 
and may indeed by present only after a day of unusual exercise or an 
especially hearty meal or some unusual excitement. 

On the other hand, hyaline casts can usually be found on long 
centrifugalization. Red blood-cells are very common, sometimes hse- 
maturia occurs. There is often a desquamation of the epithelium cells 
of the tract, giving a cloudy urine resembling cystitis. 

In the arteriosclerotic kidneys the urine contains albumin which 
occurs late and is often intermittent. Cases of the so-called " con- 
tracted kidneys with albumin- free urine " belong here, and yet in these 



316 



CLINICAL DIAGNOSIS 



cases albumin is found more constantly and in larger amounts than 
in those of the preceding group. In the arteriosclerotic group of 
" small red kidneys " when the abnormal urinary findings disappear 
for a while it is often the casts which disappear first, leaving a pure 
albuminuria ; and in the primary contracted group of " small white 
kidneys " the albumin often disappears first, leaving a pure cylindruria. 

The urea is normal, the nitrogen normal, but the percentage of 
the various nitrogenous bodies may vary somewhat, in uraemia the 
ammonia rising at the expense of the urea. Uric acid is low and 
the xanthin bases are increased. The various tests for the func- 
tional activities of the kidneys, for instance the methylene blue and 
the KI test, sometimes indicate a pathological condition but more often 
do not. The sediment is scanty and difficult to find. The urine should 
be centrifugalized and search made over large amounts of urine. 
After a long search but one or two casts may be found. These are 
usually hyaline, although sometimes finely granular. Renal epithe- 
lium is sometimes found; often a few leucocytes, rarely a red cell, 
although many may be found after overexertion. Uric acid and 
calcium oxalate crystals are common. 

During acute exacerbations of chronic nephritis the urine may 
closely resemble that of a more acute form. 

For the diagnosis of chronic nephritis one should examine the 
morning and the evening urines separately, and that voided after a 
hearty meal or severe exercise. And yet the urine in this condition 
resembles that found in other conditions so nearly that the clinical 
history and the physical examination of the patient cannot be dis- 
pensed with. The urine alone resembles that of acute or the subacute 
nephritis during convalescence, that of waxy kidney, and the cyclic, 
or the so-called physiological albuminurias. 

Amyloid degeneration may be superimposed upon any form of 
nephritis of which it really forms no part. When alone, the urine 
is said to be normal. In the majority of cases the condition could 
not be suspected from the urine, although given a case with history 
and physical signs indicating it, and the urinary changes may be well 
explained. Without the clinical features the urine would suggest, 
when concentrated, chronic passive congestion ; when dilute, small 
contracted kidney. The classical description of the urine is that it is 
increased in amount, is pale, clear, faintly acid, of a low specific gravity, 
1005 to 1012, that it contains abundant albumin with relatively much 
globulin, and very few casts. This picture of Traube, however, is rare. 
The albumin may occur in traces or fail, and the casts may be numer- 
ous. The casts are often fatty. Renal epithelium is rare, and red 
blood-corpuscles are extremely so. 



THE UKINE: KEPHEITIS 



317 



Uraemia. — Uraemia may be considered the highest expression of 
renal insufficiency, but this is not all. Compensatory changes occur 
in nephritis, and the body may become tolerant to the toxines, what- 
ever they may be. For this reason uraemia is more common in acute 
than in chronic nephritis, for in the latter the body has adapted itself 
to the condition. For these reasons, also, it is easily understood that 
the urine should show no evidence of an oncoming or present uraemia, 
for only functional activity can be tested and that but imperfectly. 

But, on the other hand, it is of interest that in cases of anuria 
due to calculus or the removal of a single kidney, uraemia and death 
may not follow for from ten to fourteen days. This is good evidence 
that the retention of urinary constituents alone is not enough to< explain 
the development of uraemia in a case of nephritis without demonstrable 
renal insufficiency. 

We have abstracted the histories of 96 cases of nephritis with 
uraemia. Of the 54 cases in which the first symptom of the nephritis 
dated back less than six months, 42 died. Of the 35 cases with an 
old history of nephritis, 29 died. Senator states that the amount of 
urine is diminished or there is even anuria. This rarely fails, and 
yet very rarely there is polyuria at the onset. The total nitrogen is in- 
creased often, but the greatest interest for us at this point is the value 
in such cases of urea determinations made by the Doremus method. 
We will not here discuss 1 the method itself. It has been used almost 
daily as a routine in all severe cases of nephritis. In only eight of 
these cases of uraemia was urea determination of possible value indi- 
cating either its onset by a drop or the improvement of the case by a 
rise. These may follow, be coincident with, or may precede the change 
in the symptoms. As the latter was true in but two cases, it is seen how 
very rarely it is that the oncoming uraemia can be foretold by the urea 
determination. Of course, in nephritis, as in all conditions, the amount 
of nitrogen eliminated depends chiefly on the amount of protein in- 
gested, and since cases with impending uraemia eat poorly, those in 
uraemia none at all, and those improving eat better, the nitrogen curve 
will depend much on the food. But the question is, Does the nitrogen 
curve rise or fall? If we can judge from the urea it falls no lower in 
uraemia than in cases of nephritis without it. 

There were 13 cases during uraemia with the urea under 1 per cent. 
We have dealt with percentages since it is almost impossible to get a 
full twenty- four hours' amount in such cases. Of these 13 cases, the 
average was 0.74 per cent. ; in one case no urea could be determined. 
Omitting extremes, in 9 cases the urea varied from 0.6 to 0.9 per cent., 
an average of 0.8 per cent. 

In 21 cases in which the urea was no help at all it varied at the 
onset of the convulsions from 0.9 to 3 per cent., an average of 1.4 and 



318 



CLINICAL DIAGNOSIS 



a mean of 1.4 per cent. The rise in urea in cases with improvement 
is striking. 

Iii 123 cases of nephritis without uraemia and without much poly- 
uria, in 33 per cent, the urea was at times at or under 1 per cent. In 
eighteen fatal cases the urea at death varied from 0.3 to 3 per cent., 
a mean of 1.2 per cent., an average of 1.4 per cent.; that is, exactly 
the same as in the above ursemic cases. 

Uraemia may occur in any variety of nephritis, and with albumin 
present from a trace to a large amount. It is interesting how little 
this striking clinical crisis is evidenced in the urine. 

One group of ten cases was interesting, since if improvement in 
condition be indicated by a diminution in albumin and casts with the 
same output of water, then uraemia may improve a case for a while 
at least. This of course may not always even suggest improvement, 
since in two the urea diminished with the albumin and casts, but in 
four it increased. 

In eight cases of terminal uraemia the albumin increased in all. 
In one case of uraemia with a trace of albumin on the day before and 
the day following, on the day of the convulsions there was a large 
amount with a great number of casts. 

In eclampsia the urinary features are similar to uraemia. 

The temporary but extreme albuminuria occurring then is quite 
striking. In a recent case in Dr. Williams's ward the albumin at 10 
a.m., March 6, contained 0.653 P er cent, albumin. The woman was in 
the first stage of labor. Convulsions occurred then. The urine till 5 p.m. 
of that day contained 1.23 per cent.; that collected till 9 p.m., 0.19 
per cent.; at midnight, 0.075 per cent.; 3 a.m., 0.025 per cent.; and 
March 7, merely a trace. That is, in about twelve hours the output 
had decreased from 1.20 per cent, to almost the vanishing point. 

In another case the total albumin was 0.4678 gms. per 100 cc, 
and the globulin 0.16 gms. per 100 cc. (34 per cent.). In still another 
case there were 18 gms. of albumin per litre, a multitude of casts and 
renal epithelium, yet at autopsy no evidence of severe trouble. 

Unilateral Nephritis. — In our series with autopsy no cases of 
this description occurred. Of 90 cases, in at least 30, or 6 per cent., 
there was considerable inequality in size of the two organs, yet in all 
but three cases, or 0.6 per cent., these were large kidneys. In these 
three cases the combined weights were 155, 190, and 205 gms., and 
the difference in weight between the two. respectively 45, 50, and 65 
gms. In a very interesting case at operation was found unilateral 
suppurative nephritis. 

Renal Atrophy. — This may be due to insufficient blood-supply, 
to cachexia, the anaemias, and especially to advancing age, the " senile 
atrophy." It is never great in amount. There are seen microscopically 



THE UKINE: NEPHJRITIS 



319 



sclerosed glomeruli, but no great increase in connective tissue. The 
urine is practically normal, and without albumin. 

Congenital Cystic Kidney. — The urine in this very rare condition 
may be normal, or show the picture of the chronic interstitial nephritis 
with small contracted kidney. The amount of urine is increased, the 
specific gravity low, with or without a trace of albumin, often much 
blood. The contents of these cysts are rather interesting, being not at 
all uniform, and in the same kidney different cysts may have different 
contents; sometimes clear, watery, almost colorless, or milky or col- 
loidal; sometimes containing urea, even in large amounts, or uric 
acid, sometimes none. Often cholesterin crystals ; colloid or proteid- 
like masses, rosette masses which resemble leucin have been described. 

Suppurative Nephritis. — In such cases we have the ordinary symp- 
toms of acute nephritis with albumin of varying amounts, but only a 
few casts. In the sediment, however, in one case there were a great 
many red blood-cells and leucocytes. In the other cases there seem to 
have been very few leucocytes. When many, the urine will be alka- 
line. Very rarely fragments of renal tissue have been found. 

There was recently in the gynecological department a remarkable 
case of unilateral suppurative nephritis. 

In cases of purulent nephritis the amount of pus which is found 
may be disappointingly small since the kidney with the abscess, either 
as a whole or in the affected part, may excrete no urine. In the 
metastatic renal abscesses there are no urinary symptoms as a rule. 

Cancer of the Kidney. — Hematuria is often an early, even the first, 
symptom. It occurs in over one-half of the cases, and is the first 
symptom in one-fourth. The amount may vary from a very slight 
trace to a fatal hemorrhage, the hemorrhage may be intermittent or 
of long duration the blood fresh or decomposed, and clots even of 
large size may be voided. Otherwise the urine is. practically normal. 

Tuberculosis of the Kidney. — In a general miliary tuberculosis 
there are no urinary symptoms as a rule, and when present they are not 
due to the tuberculosis alone. In tuberculosis of the pyramids, in which 
case it is common to have large caseous masses which break down and 
leave a cavity, the so-called " renal phthisis," the urine is similar to 
that in pyelonephritis. If it be the pelvis which is involved, caseous 
matter may be found in the urine. If the pelvis be normal there may 
be no urinary changes. The very early polyuria with or without albu- 
minuria is an interesting feature. Hematuria may be the first symp^ 
torn 1 , and was present in eight of the seventeen cases from this 
clinic which were reported by Dr. Walker. 163 This early haematuria 
is very seldom a marked or serious feature, and may last for months, 
It is present both day and night, and bears no relation to the position 

163 Johns Hopkins Hosp. Rep., vol. xii. 



320 



CLINICAL DIAGNOSIS 



of the patient, hence differs from that due to calculus. On the other 
hand it may be so severe as to be a serious feature. Pus was present 
in fifteen of the seventeen cases, in little or large amount according to 
the position of the cavity. Blood-clots are common; tissue detritus 
and masses about the size of a grain of sand occur, and in them are 
found tubercle bacilli and elastic tissue. These were present in 
nine of the seventeen cases. Albumin was present in sixteen, and 
casts in six of this series. On the other hand, the urine may for days 
be perfectly normal, and then present all the above mentioned features, 
the reason being that during this period no urine was excreted by the 
diseased side. 

In general, it may be said that in all cases of hematuria and 
pyuria, especially with acid urine, tuberculosis of the kidney should be 
excluded. For diagnosis the tubercle bacilli must themselves be found. 
But even this is not enough, since there is much evidence for the Cohn- 
heim idea of the " excretion " of these bacilli through a practically 
normal kidney, hence tuberculosis of other organs must also be 
excluded. If the disease remain limited to the parenchyma of the 
organ an entire kidney may be destroyed and yet the condition be 
unsuspected. 

In infarction of the kidney there is usually a preceding nephritis. 
In the sediment red blood-cells are usually present, but marked haema- 
turia is rare. 

In cases of bilateral infarcts, there may be oliguria, and even 
anuria. An intense albuminuria with sudden onset and rapid disap- 
pearance and no abnormal sediment is a very suggestive feature. 

Pyelitis and Pyelonephritis. — Inflammation of the pelvis of the 
kidney may be due ( i ) to an infection ascending along the ureter, or 
a descending renal infection, or an infection extending by contiguity 
from neighboring organs; (2) to local causes, stone,, cancer, tuber- 
culosis, parasites (echinococcus, amoebae, etc.), trauma, floating kid- 
ney ; or ( 3 ) to systemic causes, specific toxines of acute fevers, medi- 
cines, etc. It is usually unilateral. 

The symptoms are usually masked by those of the general or cau- 
sative disease, and even when attention is directed to the possibility 
of a pyelitis there may be no localizing symptoms to indicate it. 

The urinary features will depend on the cause. Sometimes there 
is anuria (due to the reflex influence over the sound kidney). In 
chronic cases the amount of urine is sometimes even trebled. It is 
cloudy from the pus, blood, and mucus, and faintly acid unless there 
is ammoniacal decomposition. It contains little albumin. 

Microscopically, the urine contains red blood-cells, mucus, pus, 
various epithelial cells, uric acid crystals, calcium oxalate crystals, 
fibrin coagula, tissue constituents, and other elements suggesting the 



THE UKINE: DISEASE 



321 



cause of the trouble, as tumor fragments or parasites. It has been 
a much disputed question whether from the nature of the epithelial 
cells the situation of the trouble could be determined. It seems to 
be generally conceded that the epithelium from the pelvis of the 
kidney to the urethra is quite uniform. Sahli suggests from obser- 
vation of one case that in pyelitis it is the cylindrical cells with tails 
(Fig. 46, a, b) which are especially increased. We have found many 
of these cells in several cases, but in one very acute case with autopsy 
the urine contained none. The epithelial cells are often in clusters 
with strata, presenting the well-known tile arrangement of the tailed 
club-shaped cells. There will be no casts or renal epithelial cells in 
case there is no nephritis. In the diagnosis the urine examination is 
particularly important. The reaction of the urine is usually acid. 

Of importance is the variability of the urine, the obstruction of 
the diseased side causing periods with normal urine, then the appear- 
ance of all the elements of the pyelitis. 

Various crystals are present, and in the diphtheritic form threads 
of fibrin and casts of the pelvis of the kidney, or tissue fragments. 

In the diagnosis of pyelitis, of greatest importance is the absence 
of disturbance of micturition, the homogeneous mixture of pus and 
urine, and the club-shaped tailed cells in groups with a tile-like ar- 
rangement. 

In hydronephrosis, pyonephrosis, and uronephrosis, the urinary 
changes (apart from pus) are in amount of urine, the periods of oli- 
guria alternating with polyuria, and its constituents, depending on 
the health of the cortex. 

Renal Calculus. — During the renal colic the urine may be normal 
or anuria total, but when the obstruction is relieved, blood, mucus, 
and pus appear. 

Independent of colic, hematuria is a common symptom (especially 
of oxalate stones), sometimes with the passage of a clot of blood; 
sometimes the hemorrhage is profuse, especially early. Later the 
symptoms are those of pyelitis. 

With ureteral calculi occur hematuria and oliguria, followed by 
polyuria. The oliguria is a feature in about 25 per cent, of all cases, 
and even anuria in 16 per cent. 164 

Parasitic Diseases of the ,Kidney. — In echinococcus disease 
the only urinary symptoms are in some cases a mucous catarrh of the 
pelvis of the kidney, which later may be purulent pyelitis or gangrene. 
If the large cyst ruptures through the urinary tract, there is the sud- 
den appearance of a watery fluid (or soapy or milky or bloody), and 
while the cyst is discharging the hooklets, scolices, fragments of mem- 
brane, etc., may be found in the sediment. 

164 See Schenck, Johns Hopkins Hosp. Rep., vol. x. p. 477. 

21 



322 



CLINICAL DIAGNOSIS 



(For other parasites see page 305.) In the Bilharzia infections 
(see page 305) pyelitis and even renal atrophy may result. 

FUNCTIONAL RENAL DIAGNOSIS 

During the past few years the amount of work in this very prom- 
ising field has been enormous (over fifty theses and articles have 
appeared in about seven years), but, sad to say, is rather unfruitful. 

The discrepancy between the anatomical condition as found at 
autopsy and that which would be supposed from the urinary examina- 
tions is proverbial. Small contracted kidneys of less than one-half or 
one-third normal size may excrete a urine normal in amount and spe- 
cific gravity, with but a trace of albumin and a few casts ; when the 
urine was full of casts and a great amount of albumin, no clear evi- 
dence of nephritis may be found ; again, persons have died in uraemia, 
than which there is no better evidence of renal insufficiency, and yet 
the urine contained but a trace of albumin, and at autopsy the renal 
changes were very slight. Evidently the time-honored chemical and 
microscopical methods are too gross. 

The next problem was to find a more delicate test than these to 
determine a renal condition which would be unsuspected if ordinary 
tests were used, and which would also allow of diagnosis before the 
anatomical changes were evident; also a test which would prophesy 
an oncoming uraemia. Two of the most delicate tests of physical 
chemistry were chosen, — cryoscopy and electrical conductivity of the 
urine and blood. It was hoped that the results of this work would be 
more in accord with pathological findings on the one side, and when 
these would be deceptive could we see the kidney, would show a defi- 
nite renal insufficiency did it exist clinically. In connection with these 
tests is often used the sodium chloride test. 

The third line of work disregarded the anatomical condition of 
the kidney altogether, and asked as to its functional ability. For, 
a well-compensated severe lesion is manifestly of less immediate dan- 
ger than a poorly or non-compensated slight lesion. In these tests 
an extra demand is suddenly made on the kidneys and its response 
determined. Such tests are the sodium chloride, the methylene blue, 
the rosanilin, the phlorizin, salicylic acid, and potassium iodide, et al., 
tests. 

Before describing these tests it is well to emphasize the fact that 
the toxines so evident from their results in nephritis are as yet un- 
known; and that nephritis is more a general, disease, the kidney fea- 
tures playing only one part. All that can be done is to test the way 
in which the kidneys behave toward known substances, or perform 
their ordinary duties, or the unusual which we impose upon them, and 
from this by analogy surmise how well they perform their other 



THE UBLNE 



323 



functions. Another point to be remembered is that the function of 
the kidney is not as well understood by the physiologist as the clinician 
seems to assume when he uses the methylene blue test to test the " epi- 
thelial filter," the salicylic acid to test the " glomerular filter," and 
phlorizin to test the " glandular activity" of the renal epithelium. 

Most admit that one test is never enough; that all must be used 
to get a good picture, and even with all one is dissatisfied (see the 
many French theses of 1902 to 1903, among them Miorgec, Lyon, 
1902, and Jouffray, Lyon, 1903). 

We wish to warn workers that nearly all these functional tests make an 
unusual demand on the kidneys, to which they may not be able to respond, and 
disastrous results follow. 

Cryoscopy, Freezing Point of the Urine. — By means of this deter- 
mination one hopes to find out how many molecules the kidneys are 
excreting on the one hand, how well they keep the serum free from an 
accumulation of these molecules on the other. Of these two values 
the latter is the more important, since the former will depend on the 
diet, etc. The latter is an index of the success the kidneys have in 
keeping the plasma free from the products of catabolism. It is not 
what the kidneys eliminate, but what they should but do not, which 
it is of interest to determine, and the examination of the blood gives 
some clue as to this. 

The determination of the freezing point of solutions is a well rec- 
ognized method of physical chemistry to determine the molecular 
weight of the substance in solution ; also the degree of disassociation of 
the molecules. The method, therefore, is, from the chemist's point of 
view, one of great importance. But even when the problems are 
of the simplest nature, when dilute solutions of a single and pure salt 
are used, and with but the simplest point to determine, the method 
requires experience, skill, and the due regard to a good many factors 
which can modify the results. It is hard to see, therefore, how this 
method can be applied with much success to complex fluids like 
the urine or blood, in which is dissolved a great variety of bodies of 
widely different nature, some unknown. The belief was, however, that 
from very slight differences in the freezing point of these fluids im- 
portant deductions could be made concerning the functional ability 
of the kidney. It must, of course, be remembered that the changes 
in the freezing point are exceedingly slight, varying in many cases but 
a few hundredths of one degree ; a variation which the physical chem- 
ist considers slight is that from which the clinicians draw conclusions. 
The clinician, therefore, should use even greater care than the physi- 
cist in using this method, and at least as delicate instruments. The 
reverse has, however, been true. Cheap " clinical" instruments which 



324 



CLINICAL DIAGNOSIS 



cannot be accurate are placed upon the market, and a multitude of 
freezing point determinations made with a disregard of the chances 
of error which must exclude the possibility of correct results even in 
a much simpler problem. 

The principle of cryoscopy is this : When a substance is dissolved 
in a liquid, the freezing point of the latter is lowered to a degree which 
in a general way is proportional to the concentration of the solution. 
The lowering of the freezing point of a given liquid, for instance of 
water, by a i per cent, solution of a substance, is called the " specific 
depression" of the freezing point of that liquid by that particular sub- 
stance, and a 2 per cent, aqueous solution of that same substance 
should cause double that depression. It has been found that the de- 
pression of the freezing point bears no relation to the molecular 
weights of the substance, but to the number of molecules in solution. 
In other words, equal numbers of molecules when dissolved in equal 
quantities of a given liquid will produce the same lowering of the 
freezing point whether the molecules are of the same or different 
nature. By " molecular depression" is meant that caused by a solution 
in 100 gms. of a given liquid of a number of grammes of the substance 
in question equal to its molecular weight. 

The above statements have one very important exception. They 
hold for those bodies which are not disassociated in solution. In the 
case of electrolytes — inorganic acids, bases, and salts — in dilute solu- 
tion the depression of the freezing point is at least twice that of equiva- 
lent amounts of organic substances, since electrolytes are disassociated, 
and each ion has the same effect on the freezing point as a complete 
molecule. The difficulties are at once evident. In the blood and in 
the urine we will have a large number of bodies in solution in propor- 
tions varying considerably, probably in conditions of association which 
wc can neither control nor determine. The result obtained by the 
clinical chemist is therefore a depression of the freezing point 
produced by a resultant in this mixed solution of really unknown 
nature. 

Of course, this result could be of greatest value if it were em- 
pirically shown to be so, even though the phenomenon could not be 
well explained. 

The question is, then, Does experience prove cryoscopy a valuable 
clinical means of determining renal sufficiency, or is the clinician only 
playing with a scientific toy which has for him only the appearance of 
truth ? 

Method. — The apparatus (see Fig. 62) consists of an exceed- 
ingly delicate thermometer, a, and the best is none too good, which 
reaches almost to the bottom of a test-tube, b, scrupulously clean, 
containing the solution whose freezing point is to be determined. This 



THE UEIXE: FUNCTIONAL DIAGNOSIS 



325 



test-tube is enclosed in an air-jacket 
freezing mixture of ice and salt. 

The Beckmann thermometer is generally 
used. The makers of this instrument now 
supply one for freezing points alone, which is 
a distinct advantage over the Beckmann for 
both freezing and boiling points. In the 
freezing mixture is inserted a smaller ther- 
mometer, d, that its temperature may be 
controlled, and a stirrer, e, that it may be 
kept well mixed. Before and after every de- 
termination the zero of the thermometer must 
be determined for distilled water. Of the 
same water the second zero will often be 
slightly lower than the first since the freezing 
has purified the water of carbon dioxide. The 
lower of these values is the zero of the experi- 
ment. 

The fluid whose freezing point is to be de- 
termined must cover the whole or at least over 
two-thirds of the bulb of the thermometer. In 
any accurate apparatus this will require at 
least 10 cc. of fluid, and those instruments 
advertised for 5 cc. are to be regarded with 
great suspicion. The temperature of the 
freezing mixture should not be more than 1 
to 3 0 lower than the freezing point 
of the fluid to be determined, since 
undercooling may give too low a 
point. 

The method used by the physi- 
cal chemist is as follows : Distilled 
water is put into the tube, b. 
The water is allowed to cool some- 
what below the freezing point and 
then by means of the stirrer, f, 
stirred vigorously until ice begins 
to form. The thermometer will 
then rise a little and remain con- 



Fig. 62.— Apparatus for freezing-point deter- 
minations, a, thermometer graduated to o.oi° C. ; 
d, tube for fluid to be investigated ; c, air-chamber ; 
d, thermometer for freezing mixture ; e, stirrer for 
freezing mixture ; /, stirrer for fluid ; g, jar for 
freezing mixture. 



c, which is surrounded by a 




326 



CLINICAL DIAGNOSIS 



stant. The highest temperature is the true freezing point of the 
water. This is to be repeated several times and the lowest used. The 
test-tube containing the water is then removed and that containing 
the fluid in question substituted. This also is stirred until ice begins 
to form, at which time the thermometer will rise, remain stationary for 
a few moments, and then fall. The highest temperature is the one 
to be recorded. The rise is caused by the liberation of the latent heat 
of crystallization, and the subsequent fall due to the concentration of 
the solution, since the ice formation removes just so much solvent. 
That this highest point may be the correct one it is necessary that 
the freezing mixture should not be too cool, or we may get " under 
cooling." If ice does not form, a very small crystal of ice should be 
inserted into the tube, which will start the freezing at once. 

Certain points must be observed with care : The repeated correc- 
tion of the zero point for each determination already mentioned. The 
bulb of the thermometer would better not rest on the bottom of the 
test-tube, or there may be too much ice formed here; this error is, 
however, small. The stirrer should theoretically be moved by ma- 
chinery, since its motion should be perfectly rhythmical and timed by a 
metronome; irregular stirring results in error. Since the cooling 
should be slow and the stirring take fifteen to thirty minutes, it is im- 
possible to do this by hand. 

But this careful performance of the test is seldom carried out. As 
a rule, the clinician considers the determination easy and remarkably 
rapid, and for him it is, but we are glad to say that long series of 
observations have been made by those who have observed all the above 
precautions, and their work (mentioned later) is alone of value in 
judging the method. 

Some go so far to the other extreme as to say that the molecular 
concentration may be easily determined by multiplying the last two 
figures of specific gravity by 0.075. 

To determine the freezing point of urine it is better to use a 
twenty-four hours' mixed specimen than to test separate voidings. 
The vessels in which this is kept should be perfectly clean. If rich in 
urates the freezing point of the cloudy fluid may be determined, and 
to the result 0.04 0 added or the fluid may be cleared by centrifugali- 
zation and the freezing point of the clear fluid and sediment deter- 
mined separately. 

Linossier and Lemoine 165 have shown that the position of the 
patient is important, since excretion is very different when erect from 
when in bed, being even five times as much in the latter position. 

Blood. — This is best obtained through a canula in the median vein 
at the bend of the elbow. One must be sure, however, that the cir- 
165 Compt.-rend. Soc. Biol., vol. lv. pp. 469, 605. 



THE URINE: FUNCTIONAL DIAGNOSIS 327 



culation is perfectly free before the blood begins to flow, since the 
venous stasis alters the freezing point considerably. Serum, defibri- 
nated blood, or the pure blood may be used with theoretically the same 
results. Most of the better workers, however, prefer the serum. The 
defibrinated blood has the error of the high C0 2 -content which can 
make a difference of 0.02 °. It is better to let the blood clot in an 
air-tight vessel, or to condense the clot by centrifugalization. At least 
40 cc. of blood in the first case are necessary in order to get enough 
serum; in the second case, from 25 to 30 cc. Two determinations 
should be made, the observer being sure that the serum is perfectly 
thawed between them. 

In the following paragraphs 8 = the depression of the freezing 
point of blood ; A that of urine. 

The results obtained were at first considered promising, but more 
recently the method has not received the same approval. Koranyi, 
who brought the method into prominence in 1896, was exceedingly 
sanguine. He considered that 8 was very little lowered, that is, 
below 0.56 0 C, in anaemias and fevers which do not affect respiration, 
but was lowered considerably by any disease causing insufficiency of 
respiration, or renal insufficiency, or both. He thought that cryoscopy 
would help the diagnosis between typhoid fever and pneumonia, since 
in the latter 8 is lowered. In renal disease, for J to be high (i.e., 
abnormally near o°), means renal insufficiency. From cryoscopy of 
the urine he believed in anaemias j to be less than 1.4 °, a point which 
is considered normal. In nephritis it is very little less, but in anaemias, 
in renal insufficiency, and in malnutrition is molecular oliguria present 
(about — 0.80 0 C. ). It is seen that he expected much from this 
method. 

The freezing point of normal serum in man is much less variable 
than that of any other animal, it being from — 0.55 0 to — 0.57 0 C. In 
case both kidneys of an animal be removed, the effect on the blood is 
enormous, even— 0.75 0 C, but a partial injury has a less effect, Ko- 
ranyi stating that one-half the renal parenchyma could be destroyed 
before any effect was shown. 

The remarkable ability of the body to keep 8 constant is seen in 
the case mentioned by Kiimmel, in which 8 was — 0.57 0 C. before an 
intravenous injection of 2000 cc, and four hours later exactly the 
same. This writer in a long series of observations found almost 
always when there was unilateral disease a lowering of 8. 

The amount of work done with cryoscopy is enormous, at first 
quite promising, but later less so. Our own experience is not suf- 
cient to report. We think the present status well given by Schoen- 
born (Wiesbaden, 1904), who has done some very careful work 
with this method. Forty-two cases of nephritis were studied and 



CLINICAL DIAGNOSIS 



the various formulas applied. His conclusions are that the ordinary 
methods of urine examination, the microscopical and chemical, are 
of more value than cryoscopy of the urine and blood; that clini- 
cally the latter can be omitted but the former never. He found that 
from cryoscopy no information was gamed concerning the nature of 
the processes, the functional ability of the kidney, or the severity 
of the disease. It is true that the majority of cases will conform 
to certain rules, but one is so often deceived, the number of excep- 
tions to these g'eneral rules so great, and in all probability their num- 
ber will increase so greatly on further work, that the value of this 
alone is to be much doubted. As a delicate method of predicting any 
future change of the patients' condition or of detecting a latent nephri- 
tis which cannot be recognized by the ordinary clinical methods, he 
doubts that it is of any value. 

In most of his cases J fell within those limits usually considered 
normal, and some of these were the severe ones. In the severest cases 
S did drop, yet gave no indication of the nature of the lesion. 

In uraemia it is granted there is the most serious renal insufficiency, 
and hence this is the condition by which the method can be best tested. 
He concluded from the study of 88 cases, including nine of his own. 
that cryoscopy in some cases shows a normal condition, in the ma- 
jority of cases the same condition as of nephritis without uraemia, and 
in only a few cases a striking abnormality, as, for instance, 8 = 
— 0.975° C. Engelmann on the contrary reported a series of 36 cases, 
S averaging — 0.664 0 C. Again, in cases with no suspicion of renal 
insufficiency S could be very high, even — 0.67° C. 

In surgical cases with a gross bilateral renal lesion destroying all 
the functions a good parallelism between the lowering of § and the 
development of the uraemic symptoms may be followed (Kummel), 
but in medical cases this is not so true, since the lesion, whatever it 
may be. in some way brings about uraemia while those renal functions 
which we can measure are still well performed. 

According to the medical men. therefore, the cryoscopy of the 
blood and urine gives some idea of the osmotic activity of the kidneys 
which is not given by any other method : this idea enlarges in some 
cases the clinical picture and is of some value, but it rarely gives any 
information which could not be learned from the ordinary methods. It 
never foretells an oncoming uraemia, or decides the nature, the prog- 
nosis, or the results of therapy, or reveals a condition not already sus- 
pected. It is a method which requires a great deal of practice, and the 
accurate control of a great many conditions, both in its performance 
and in the previous care of the patients, such as diet. etc. The results 
obtained by the skilful are interesting, in some cases valuable, in the 
majority disappointing, and in some deceptive. The cryoscopy of the 



THE UKINE: FUNCTIONAL DIAGNOSIS 



329 



blood alone demands considerable experience, and gives little more than 
would be expected from the clinical observation of the case, and often 
not that much. The cryoscopy of the urine is of very little value even 
when greatest care is taken concerning diets, fluid, etc. Schoenborn 
examined 52 cases of non-nephritics with many diseases, and found it 
of practically no value whatever in differential diagnosis or to follow 
the results of therapy. He admits that the conditions of the kidney and 
cortical vessel are the most important factors governing 8 and A, 
but there must be other unknown factors in some cases still more 
potent. From the study of all these cases no general deduction could 
be made. 

Strauss, 166 who carefully governed the food and water intake, also had found 
cryoscopy of the urine unsatisfactory, and evidently more cases atypical than 
typical. For the value of cryoscopy in hepatic diseases, see Ferrannini. 167 Cryos- 
copy has also been used for the quantitative determination of albumin and sugar, 
but without much success. 

Among the various formula used in the hope of getting con- 
stants for use are the following: 

A = depression of freezing-point of urine ; 8, that of blood. 

a x amt. of urine (V),~, , . . . , N , , . f 

—■ . — ; — (Claude and Balthazard) " the total molecular diu- 

body weight (P) v ; 

resis ;" the index of "glomerular filtration ;" this was found inconstant. 

A x amt. of urine, Strauss' "valence value," is useful; the "molec- 
ular diuresis" of Koranyi. 

A x amt. of urine ^ T . ■ ,, ' T;r . , . 

— - "NaCl equivalent 01 Koranyi (a of 1 per cent. 

NaCl = 0.613). 

A 

N per cent. 



(Waldvogel). 



Sp. gr. of urine. 

Nad (K° ran y')- 

— is of value indicating the permeability of the epithelium of the 



tubules. 

A x amt. of urine 



(Bernard). 



8 V 

— — an approximate index of urinary toxicity. 

Electrical Conductivity. — This method of physical chemistry also 
has been appropriated by the clinician in his desire to learn something 

166 Zeitschr. f. klin. Med., 1902, vol. xlvii. p. 39. 

167 Centralbl. f. inn. Med., vol. xxiv. p. 273. 



330 



CLINICAL DIAGNOSIS 



about the functional ability of the kidneys. By electrical conductivity 
is meant the reciprocal of the resistance which a certain amount of a 
solution between two platinum electrodes of given size and given 
distance apart offers to the passage of a current of known strength. 
This is really a measure of the number of electrolytes in solution, that 
is, of the disassociated ions. It is not affected by such bodies as albu- 
min, sugar, urea, which are not disassociated, and hence is practically 
a measure of a few salts in the blood and urine, especially the chlorides. 
This also is a method which is very valuable to the physical chemist 
of experience to determine simple points concerning simple solutions, 
and even for him to draw deductions requires a full understanding 
of all the conditions present in the determination. It would seem, 
therefore, like one working in darkness to apply this very delicate 
method to solutions, such as the blood and urine, which contain an 
unknown mixture of various bodies which, because of this mixture, 
may not disassociate as they would were they in pure dilute solution. 
Yet if found by experience to be of value, no theoretical objection 
should be urged against it. 

Method. — The method of Kohlrausch is that usually used. By 
this method an alternating current is passed between platinum elec- 
trodes through the solution whose conductivity it is desired to study. 
The resistance is balanced on a Wheatstone bridge against a rheostat, 
and the point of equilibrium determined by means of a telephone. 
The urine, for instance, is placed in a U-shaped tube of known length 
and holding 4 to 8 cc. of fluid, in which are immersed the platinum 
electrodes, which must be very carefully prepared and covered with 
platinum black in order to secure a sharper minimum in the tele- 
phone. This vessel containing the urine is placed in a thermostat, 
the temperature of which does not vary over o. 1 0 C. 

For detailed description of the method standard works on physical 
chemistry should be consulted. But this method has been popularized, 
and on the market are instruments for " clinical use" which allow of a 
rapid determination and, which is their chief advantage, require a very 
small amount of urine ( 1 to 2 cc. ) . 

The conclusions thus far are that the electrical conductivity in the 
case of the blood and the urine is somewhat parallel to the freezing 
point and gives nothing definite. Many abnormalities are found, but 
one does not know how to interpret them. For this reason we refrain 
from a more elaborate description of the method. 

The delayed excretion of urea is an old criterion of functional 
renal ability. In acute disease it may take three to six days to 
excrete the urea formed from one day's meals; in chronic nephritis 
and renal tuberculosis, two days. During this delay the urea accumu- 
lates in the blood, and may be determined quantitatively (see page 



THE UKINE: FUNCTIONAL DIAGNOSIS 



331 



547). When it is increased tenfold (i. e., to 0.3 per cent.), there is 
danger of uraemia (Herter). 

Chloride Excretion. — The rapidity with which the kidneys can 
excrete a considerable amount of sodium chloride is taken as a test 
of its functional ability, or, as some specify more particularly, of the 
" glomerular sufficiency." 

This test of " alimentary chloruria," recommended by Claude and 
Mante, 168 is used usually in conjunction with cryoscopy. It consists 
in placing the patient on a milk diet (3 1. per day), and after the third 
day adding sodium chloride, 10 gms. a day, dissolved in 125 cc. of 
water, which are given in three portions on each of four consecutive 
days. The daily output of the chlorides is determined. 

Normally the excretion begins at once and ends abruptly when ingestion 
ceases. The water output is increased, but to a less degree. The other constituents 
of the urine are also slightly increased and continue so for a longer time than the 
increase in CI. 

These writers divide renal cases into four groups : the first, of those who 
react exactly as normal persons do ; these bear their lesion well. In the second 
group the increased chloride excretion causes a considerable increase of other 
urinary constituents, especially the nitrogenous bodies, which continues several 
days, as if the sodium chloride had acted favorably on the kidneys. In the third 
group the increase in chlorides is delayed, reaches a slow maximum, and continues 
two to four days after ingestion ceases. There is also an increased output of other 
bodies, but it is less in this than in the second group. In the last group the inges- 
tion of salt causes no increased CI output, no (or a slight) diuresis results, and 
the excretion of other bodies is increased. The prognosis of the third group is 
bad ; of the fourth, fatal. 

Yet further work has shown that there is nothing constant in this 
excretion in renal disease ; there are too many exceptions, and not 
always can these be interpreted. 

The Dilution Test. — Some consider the change of zf after inges- 
tion of increased fluid of importance. In parenchymatous nephritis 
the ability to excrete a dilute urine is decreased more than it is in 
contracted kidney; that is, the case is judged from its water economy. 
In surgical cases also this test is considered a valuable adjunct. After 
determining J, etc., the patient drinks in a short time 1 to 2 litres 
of water. The amount excreted and the A of the dilute urine are then 
determined. The urine is collected in half-hourly amounts. The in- 
crease often begins during the second half-hour, reaches a maximum 
in two to three hours, and is over in five to six hours. 

Among the other terms used are " glomerular insufficiency," which 
means the retention of water and NaCl, the excretion of a scanty con- 
centrated urine, the inability to excrete a dilute urine. " Tubular 
insufficiency," the retention of nitrogen and phosphates, the excretion 
of a normal amount of dilute urine, the inability to excrete a concen- 
trated urine. 

168 Arch. gen. de med., 1902, vol. viii., n. s., p. 129. 



332 



CLINICAL DIAGNOSIS 



Renal Permeability. — The methylene blue test (of Achard 
and Castaigne) is supposed to test the " epithelial nitration." This 
dye may be given by mouth, o. i gm. in a capsule, or 0.05 gm. subcu- 
taneously, that is, intramuscularly ( 1 cc. of a 1 : 20 solution of me- 
thylene blue). This latter is the better method, since the disturbing 
factors on the part of the digestive canal are eliminated. 

The dye is eliminated, first as a colorless chromogen in fifteen to 
thirty minutes after a subcutaneous injection, and as a greenish-blue 
pigment three to five minutes later. To appear first only after an 
hour is pathological. Normally the excretion reaches a maximum in 
from three to four hours and lasts from thirty-five to fifty hours 
(forty-eight to sixty) ; the chromogen is last to disappear. About 
one-half is eliminated in the first twenty-four hours. 

As soon as given the bladder is emptied and the urine examined 
at stated periods, first in half an hour, then hourly. It is boiled with 
acetic acid to oxidize the chromogen. The time is measured from 
the appearance of the colorless pigment thus made evident until this 
chromogen disappears. 

It has been noted that toward evening the elimination ceases, to be 
resumed the following morning. Others show a " poly cyclic" elimina- 
tion, i.e., a very irregular curve with periods in which none is elimi- 
nated. This is seen in interstitial nephritis and various neurotic 
conditions, but is said to be especially true of " hepatic insufficiency" 
(Pugnat and Revilliod). 

But the delay or non-delay of elimination is not of great impor- 
tance, since even a small amount of normal renal tissue in an exten- 
sively diseased kidney will excrete some at the normal time, hence 
the amount excreted is considered of greater value. The results of 
these tests of the renal permeability in the hands of its friends, espe- 
cially the French, may be stated as follows t^The delayed and pro- 
tracted excretion depends directly on the acuteness of the process; in 
chronic parenchymatous nephritis, as a rule, the permeability is good ; 
also in some cases of chronic interstitial nephritis. Others say that 
in nephritis the excretion is always delayed; that when elimination 
begins in normal time either the kidneys are sound or the lesion local. 

In some cases the excretion is delayed and lasts longer than nor- 
mal, even seven days, and the total output is less. This is seen in renal 
atrophy, and is considered a sign of " diminution of the excretory 
surface" (Achard). In some cases " with epithelial lesion predominat- 
ing" the kidneys seem abnormally pervious, the excretion begins in a 
very few minutes, and continues but about twenty-four hours (Bard). 
In a third group it begins late, but lasts only a short time; e.g., 
Widal's case began at the end of five hours and lasted but two hours. 
The greatest abnormality is therefore in interstitial nephritis, while 



THE URINE: FUNCTIONAL DIAGNOSIS 



333 



in parenchymatous or amyloid the test may show a normal or abnor- 
mally rapid output. 

Herter, while admitting that a delay means disease, agrees that 
some patients show periods of normal output. He denies that in any 
case is there a shortened period of excretion. 

From the first the test has been severely criticised (especially by 
Germans). Too many cases with kidneys found at autopsy to be the 
seat of extensive disease reacted normally or with abnormal rapidity. 
In uraemia even the test may show normal permeability (but see 
Bard's case). The variations are not marked enough; it is not rea- 
sonable to judge of the permeability of the kidneys to normal or 
abnormal constituents from the excretion of this very abnormal body, 
and since the permeability for methylene blue is known to be different 
from that for known bodies, it may be very different from that for the 
toxine causing uraemic symptoms; while, on the whole, in nephritis 
there is delayed and abnormally protracted excretion, yet the various 
forms of renal disease show little or no difference ; the permeability is 
altered even in neuroses. In some cases the dye is entirely destroyed 
in the body, not even the chromogen appearing in the urine. And 
lastly, even the warmest friends of the test have modified it, and now 
emphasize the total output of the dye as of most importance, which 
causes one to mistrust the test, for this quantitative determination is 
uncertain, hard, and it is not at all certain that this amount would be 
any good index of renal activity. 

Salicylic Acid Test. — This test was adapted to clinical use by 
Widal and Ravant as a measure of renal permeability. One cc. of a 
30 per cent, solution of sodium salicylate is injected (with a little 
cocaine to reduce the pain) intramuscularly. The urine is examined 
at the end of half an hour, then hourly, with 10 per cent. Fe 2 Cl 6 solu- 
tion. Colorimetrically can the amount excreted be determined. 

Normally the violet color is given by the urine voided at the end 
of half an hour, even of fifteen minutes ; it reaches a maximum in 
from one to three hours, and disappears in from eight to twelve hours. 
The amount excreted (i.e., the per cent, of the total) in five hours 
is taken as a sort of standard. The excretion is supposed to be 
through the glomeruli and governed by physical laws alone. In the 
various forms of nephritis the excretion may begin within the first half- 
hour (yet perhaps in the first fifteen minutes), and reach a maxi- 
mum at the same time for all. In some of the cases of paren- 
chymatous nephritis there is the same duration of excretion and 
the same relative output in five hours as normal, but in some in- 
terstitial cases the output is continued over a long time and is less 
in amount; yet in even the very few cases reported there are striking 
exceptions. 



334 CLINICAL DIAGNOSIS 



It has certain advantages over the similar potassium iodide test, 
since it is simpler and more rapid. 

If a quantitative estimation be desired, Ziegan 169 recom- 
mends the following: To from 30 to 50 cc. of urine in a graduated 
mixing cylinder are added 1 cc. of dilute H 2 S0 4 and 50 to 80 cc. of 
ether, and shaken three to five minutes. This is allowed to settle. 
One-half the ether extract (with the salicyluric acid) is removed by a 
pipette and poured into a separating funnel. To it is added 2 per cent. 
Fe 2 Cl 6 , till the color does not change. It is then poured into a glass 
suitable for color determinations. Into another glass of exactly the 
same character is poured an equal volume of ether, the same amount 
of 2 per cent. Fe 2 Cl 6 which was added to the first glass, and then 0.1 
per cent, of salicylic acid from a burette until the same shade is 
obtained. 

For the quantitative estimation of KI see Singer. 170 
Phlorizin Test. — This test of the " secretory ability" of the renal 
epithelium, rather than the " permeability," for which latter function 
osmosis is supposed to play the important part, in the former none, was 
proposed by Achard to replace the hippuric acid test (the ability of 
the kidney to transform benzoic to hippuric acid ; a theoretically good 
test of renal functional ability, but clinically useless since the deter- 
mination of hippuric acid is so inexact). The test is, of course, based 
on the generally accepted view that phlorizin diabetes is due to the 
activity of the renal cells and that a diminished or absent glycosuria 
means renal disease. One cc. of a 1 : 200 solution of phlorizin 
(hence 0.005 S m -) ls injected subcutaneously (a small dose is chosen 
which will produce glycosuria in only normal kidneys). The blad- 
der is emptied, then sugar tested for at intervals. In normal persons 
sugar will appear in from one-half to one rfour, and be present for 
from two to four hours. The quantity eliminated is 0.5 to 2.5 gms. 
of glucose. In nephritis, as a rule the sugar is below 0.5 gm. or is 
absent. Abnormalities in the test may not always indicate renal lesion 
but more or less functional disturbance of that organ. The test does 
not permit one to separate the various forms of nephritis, the " hypo- 
glosuria," and " analglycosuria " occurring about equally in all forms. 
Yet it is a good test of renal activity and tests a quite different function 
from the others. 171 

The Value of these Tests to the Surgeon. — In the medical wards 
these tests may be said to add to the clinical pictures of cases, but for 
diagnosis not much weight is given them. For surgical conditions the 
case is very different, and these tests are of great value, when, e.g. } the 

169 Centralbl. f. inn. Med., 1903. 

170 Zeits. f. klin. Med., 1903, vol. xlviii. p. 157. 

171 Pugnat and Revilliod, Arch. gen. de med., 1902, vol. viii. p. 19. 



THE UKINE: FUNCTIONAL DIAGNOSIS 



335 



question is the justification of removing a diseased kidney. In such a 
case the first question is, the presence of another kidney ; the second is, 
can this second kidney do the work of both ? To decide these questions, 
if by means of ureteral catheterization we can separate the urines ex- 
creted at the same time, a comparison of these is of value in determin- 
ing - , first, the presence of the second kidney ; second, the relative values 
of their activity; while the freezing point of the blood will determine 
their united insufficiency; i.e., as in medical cases, if lowered, a con- 
traindication to operation. It is of interest that the confidence of the 
medical men in these tests has decreased, while that of the surgeons 
has increased. 

The chief difference between these two points of view may be that 
surgical cases are chiefly of renal disease which destroys all renal 
function, while among the medical cases there are so many in which all 
the functions which can be tested are normal, but that unknown but 
all-important one, failure of which means uraemia, escapes detection. 
Kiimmel 172 stated that he had in a long experience (in over 500 
cases) never been deceived by cryoscopy of the blood, while Casper 
and Richer 173 consider the cryoscopy of the separated urines, 
together with the phlorizin test (determination of the amount of 
sugar eliminated by each kidney) — neither test alone but the agree- 
ment of both — of actually greater value than the microscopic or 
gross examination of the renal tissue. The surgeons take it 
for granted that the secretion of two normal kidneys at the same time 
is quite equal. Since it may vary much at different times, even 
in eight minutes reaching in normal persons figures which would be 
considered pathological, the collection from the two kidneys must be 
simultaneous ( Casper and Richer). Others think that for short inter- 
vals the renal activity is scarcely equal and that at least two-hour 
specimens should be collected to be sure of an equality. The kidney 
can be said to- be insufficient, when A is less than — 1° C, unless the 
urine be diluted by recent intake of fluid. 

The methylene blue test is of little value, since one cannot collect 
separated urines for a long enough time to determine the beginning, 
the end, and the intensity of secretion of this dye. Yet the surgeons 
do use it to determine whether the fluid from a sinus is urine or not. 
The phlorizin test is more valuable, since one can determine the time 
of onset, duration and intensity of the sugar excretion if he allows the 
catheters to remain in the ureters but three hours. But this is not neces- 
sary, since one determination of the sugar excreted by each kidney is 
a good index of the relative amount of renal activity of the two sides. 
The urine should be examined by the polariscope in from one-half to one 

172 Centralbl. £. Chir., 1903, vol. xxx. II. p. no; also Arch. f. klin. Chir., Bd. 67. 

173 Functional Diagnosis of Kidney Disease, 1903. 



336 



CLINICAL DIAGNOSIS 



hour after the injection. Barth, 174 who used the method of Casper and 
Richer, says that examination of the separated urines gives not an ab- 
solute, but a relative picture of the functional ability of the two kidneys. 

Gobell 175 also determines only A, and warns one that he cannot 
trust these functional tests implicitly. The patient should be for several 
days on a constant diet, the ureters catheterized at the same time after 
a meal, and the catheters left in place two to three hours to collect the 
urine. From A one cannot tell whether or not the remaining kidney 
will be sufficient. 

The dilution test has proved of very great, some say the most, 
value to the surgeon, the diseased kidney not responding as well as the 
other. The catheters are left in place for from three to five hours. The 
urine is first examined, the patient drinks 1.5 to 2 litres of water, and 
the voiding for each kidney is examined especially with regard to 
amount and A. 

The increased output on the normal side may begin during the sec- 
ond half-hour and reach a maximum in from two to three hours ; the 
diseased side may show no increase. 176 

Kiimmel, on the other hand, considers the freezing point of the 
blood more important, and mentions 72 cases of nephrectomy without 
a mistake in judgment concerning the sufficiency of the second kidney, 
whether sound or slightly diseased. As a proof of the value of cryos- 
copy he states that before its use mortality of renal surgery was 28 
per cent. ; since its use, 8 per cent. ; and of nephrectomy, 4.8 per cent. 

Kiimmel found in those cases in which there was an unconfirmed 
suspicion of renal trouble a constant 8 of 0.56 0 , with 0.54 0 to 0.58 0 as 
limits. (These figures all refer to depressions of the freezing point. 
When one says 8 = 0.56° C. he means that the freezing point was 
depressed that much, that is, that the temperature of the freezing mix- 
ture was — 0.56 0 C, or t° = — 0.56° C. ) In the second group was 
disturbance of total renal function, bilateral nephritis, pyelonephritis, 
etc., with 8 = 0.60° to 0.65°, limits 0.59° to 0.81°; in these surgical 
cases of uraemia (prostatic cases e.g.) was a definite parallelism be- 
tween the molecular concentration and the ursemic symptoms. In a 
long interesting series of cases of other than renal disease he finds 8 
practically normal. He says that for him 0.6° is the limit of safety. 
If below this limit, although the one kidney may not be strictly nor- 
mal, yet it is sufficiently so to do the work of both. The third group 
is a long series of cases of unilateral disease ; when strictly unilateral, 
in all 8 was normal. In such cases ureteral catheterization showed on 
the affected side A low and urea diminished, while the other side was 

1? * Centralbl. f. Chir., 1903, vol. xxx. II. p. 134. 

175 Munch, med. Wochenschr., 1903. 

176 Illyes and Kovesi, Berl. klin. Wochenschr., 1902, p. 321. 



THE UKINE: FUNCTIONAL DIAGNOSIS 



337 



normal. In cases of apparently unilateral disease with 8 normal, in 
no case did subsequent history show that there had been a bilateral 
disease. Cryoscopy may also be used in differential diagnosis; e.g., 
if the question lies between renal calculus and hemorrhagic nephritis 
with unilateral pain, a high 8 would speak for the latter; in prostatic 
hypertrophy the presence or absence of an ascending disease can be 
settled by determining S; that a tumor is renal can be suspected by 
the low J of that side. 

Recently it has been suggested that instead of methylene blue 
indigo-carmine, 3 cc. of a 4 per cent, solution injected subcutaneously, 
be used to- test the functional ability of the kidneys. The advantages 
claimed for this dye are that it is excreted entirely by the kidneys, that 
its excretion begins in a few minutes and is soon over, and that no 
colorless excretion products are eliminated. 



CHAPTER III 



THE STOMACH CONTENTS 

THE VOMITUS AND GASTRIC CONTENTS 

The various forms of vomiting have been grouped as follows : 

Cerebral : in brain and cord disease, as tabes, insular sclerosis, men- 
ingitis of brain or cord, cerebral anaemia or hyperemia, concussion of 
the brain, brain tumors, etc. 

Toxic : opium, tobacco, ether, chloroform, alcohol, uremia, chol- 
semia, pregnancy, et al. 

Psychical : disgust, fright, anger, and other strong emotions. 

Periodic: "cyclic," "recurrent," a form with sudden attacks of 
vomiting, often without apparent cause, and sometimes accompanied 
by intermittent hyperchlorhydria. There is evidence that some of 
these cases, especially of children, and which resemble a secretory neu- 
rosis, are due to an acidosis, i.e., an autointoxication. 1 

Neurasthenia and hysteria: An interesting case of neurasthenia 
with very obstinate vomiting, as a rule, vomited repeatedly from 
three to four hours after the stomach was washed out. Each time she 
vomited from three to four ounces of bile-stained fluid. 

Reflex : as in peritonitis, strangulation of the bowel, sexual dis- 
turbances, cholelithiasis, renal colic, intestinal worms. 

Local : due to gastric conditions, whether acute or chronic, and 
especially those with stasis of the gastric contents. 

The Vomitus and General Considerations concerning the Gastric 
Contents. — Considerable may be learned from vomitus, yet less than 
from a test meal. The gross inspection is valuable, its microscopical 
examination less so, and its chemical often misleading, for we seldom 
know the condition of the stomach previous to the meal which is vom- 
ited, nor always the character of this meal, at least we are sure it 
was of no standard quality and amount ; the time element cannot be 
controlled, and it contains mucus and saliva from the mouth. Our 
test meal analyses, conducted with the greatest of care observing all 
of these points, are none too satisfactory, hence the examination of 
vomitus apart from its gross appearance is even less so. 

The reaction of vomitus, with the exception of a few cases of 
achylia, those with intestinal contents mixed, and a few cases of cancer 
of the stomach with alkaline gastric contents,, is acid to litmus. If 
free hydrochloric acid is present it is an important point to exclude 
fluid from diverticula of the oesophagus. 

1 Edsall : Snow, Am. Jour. Med. Sci., 1904, vol. cxxviii. 

338 



THE GASTRIC CONTENTS 



339 



The character of the vomitus is important; abundant, thin, acid 
fluid, with food eaten the previous day, means dilated stomach; very 
fluid, strongly acid juice free from food means continuous secretion; 
thin acid fluid with finely divided fragments of food suggests ulcer; 
thick masses with much mucus and poorly digested often decomposing 
meat suggest chronic catarrh and cancer of the stomach ; recently eaten, 
undigested food suggests nervous vomiting. If the vomiting occurs 
at the height of digestion and during a paroxysm of pain which then 
at once diminishes, one thinks of ulcer; if during or shortly 
after eating, of cancer, catarrh, or a neurosis; if independently of eat- 
ing, often mornings before breakfast, and it contains not only mucus 
and bile but also food remnants, of ectasis. Cerebral vomiting is often 
marked by a noticeable absence of straining or effort; vomiting on 
rising in the morning is suggestive of pregnancy, or, in the case of 
men, of alcoholism ; with cancer at the cardiac orifice vomiting follows 
a meal ; if there be pyloric stenosis due to any other cause the vomit- 
ing occurs later, at longer intervals, and in large quantities. 

A very slight blood streaking of vomitus and gastric contents is 
of no moment, since from the effort of vomiting or by the stomach- 
tube slight lesions of the oesophagus or pharynx may result. 

Bile and Pancreatic Secretion. — Traces of bile are often 
present in vomitus from a fasting stomach, at the end of lavage, and 
in vomiting attended by severe retching. This has no significance 
unless it be constantly present and there has been no straining sufficient 
to force bile from the duodenum into the stomach. In case it is con- 
stantly present, it might indicate stricture of the duodenum below the 
ampulla. On the other hand, a green color does not always indicate 
bile, since a few cases are recorded 2 of " grass green," " sea green,"" 
" dark green " vomitus, the color of which is due to alga? or at least to 
chlorophyll-colored protophytes. Bile-stained vomitus is particularly 
common from an almost empty stomach, less so from a full one, in 
which case there is more counterpressure against the pylorus, prevent- 
ing the regurgitation of bile. For this reason it was thought the 
vomitus of peritonitis was more often bile-stained than of cerebral 
troubles, since in the former cases the stomach is more often empty. 

Mucus in the vomitus is almost constant. Seldom, however, does 
it indicate gastric catarrh, a condition which is rare compared with 
the number of times that the diagnosis is made. It may be due to 
catarrh, but is more often to lack of hydrochloric acid and hence lack 
of digestion of the mucus that is normally secreted. The morning 
vomitus of alcoholics contains large amounts of mucus. 

Large amounts of acid gastric juice, sometimes pure, sometimes 
mixed with food, are common in cases of hypersecretion, the former 

2 See Kuhm. Zeitschr. f. inn. Med., 1902, No. 28 ; 1903, No. 1. 



340 



CLINICAL DIAGNOSIS 



especially in cases of gastroxynsis, a neurosis with periodic attacks 
of acid vomiting. If food be present in this case the proteid will be 
well digested, the starch less so. 

The vomiting of large amounts in which is food eaten two or three 
days previously occurs in cases of stricture of the pylorus with dilata- 
tion of the stomach. In this vomitus the proteid will be poorly digested 
and badly fermented in case of cancer, etc., well digested with fer- 
mentation of carbohydrates in benign cases due to ulcer, etc., this 
depending on the presence 'or absence of hydrochloric acid. 

Fecal vomiting occurs when there is complete obstruction of the 
ileum or the colon, or paralysis of the intestinal wall due to peritonitis, 
etc. The patient vomits repeatedly and each vomitus is more fecal 
than the others, so that it is easy to say approximately from what part 
of the intestine each comes. Finally the vomitus is the black, foul- 
smelling contents of the colon, which microscopically contains vast 
numbers of bacteria. Yet the absence of fecal vomiting does not 
always exclude a total obstruction, as when it is high in the jejunum. 
For the vomitus to have even a suggestive fecal odor the obstruction 
must be at least six feet from the pylorus. 

Rice-water vomitus is seen in Asiatic cholera. It is very fluid 
and filled with white flakes of mucous shreds and epithelial cells (see 
page 37.3). 

From the color and the odor of the vomitus cases of poisoning or 
alcoholism may be suspected. In ursemic cases it has an ammoniacal 
odor. 

Some idea of the motility of the stomach may also be obtained, 
since if any food is vomited seven hours or more after the last meal, 
motility is certainly diminished, although this may be a very tempo- 
rary condition. At the end of two or three hours particles of meat 
should be swollen and show considerable evidence of digestion. At 
the end of one hour bread should have been broken up to a fine, 
crumbly sediment, which settles to the bottom of the glass. If there are 
large particles of bread, and especially if these are coated with mucus, 
hydrochloric acid is quite surely diminished. 

The chemical analysis of vomitus, as stated above, is exceedingly 
unsatisfactory. If free hydrochloric acid be present we are sure that 
it is secreted, but, if absent, we can draw no conclusions. In general, 
it may be said that normally both free hydrochloric acid and pepsin 
are present two hours after a mixed meal. 

Lactic acid may be expected after a mixed meal. 

The microscopical examination is also unsatisfactory, since normally 
both intact muscle-fibres and starch granules pass to the intestine. 

The antiseptic condition of the stomach may also be judged. The 
presence of organisms may be due either to the absence of hydrochloric 



THE GASTRIC CONTENTS 



341 



acid or to stasis. The voniitus may be foamy and have the odor of 
butyric or other organic acids. In cases with free hydrochloric acid 
and severe stasis the majority of organisms are yeasts and sarcinae; 
in lighter cases of stasis the fluid is sterile ; in those cases, as of cancer, 
without free hydrochloric acid, bacteria predominate. 

Tumor fragments occur, but are rarely found. In the vomitus 
may be found round worms, segments of tape-worm, oxyuris, mag- 
gots, etc. 

Examination of the Fasting Stomach. — While from the normal 
fasting stomach theoretically no fluid should be obtained through the 
stomach tube, yet it is very common to get from 10 to 50 cc. of an 
acid gastric juice. There is considerable discussion as to what amount 
is certainly abnormal, and the limit given by Boas of 100 cc. is a safe 
one. This much means hypersecretion or motor insufficiency. The 
question may be settled by washing the stomach out at night ; if due 
to motor insufficiency, the stomach will be empty in the morning. Rie- 
gel insists that the fasting stomach is always empty, even a little true 
gastric juice is pathological, and that the few cubic centimetres found 
is not normal digestive fluid. 

The fluid from the fasting stomach is thin, specific gravity 
1004 to 1005, contains some free hydrochloric acid, no lactic acid, and 
no bacteria. It is very commonly bile-stained, but this is not important 
unless repeatedly so, in which case duodenal stricture may be suspected. 
It may be alkaline from the presence of pancreatic juice, in which 
case trypsin should be tested (see page 384). Should the fluid be 
neutral or even acid from hydrochloric acid, soda must be added at 
once to prevent the destruction of the trypsin. The presence of ab- 
normal amounts of mucus may be determined, such as occurs in an- 
acidity, atrophy of the mucous membrane, etc., but considerable wash- 
ing is necessary to dislodge the mucus from the mucosa. 

Test Meals. — The Ewald-Boas test breakfast consists of 
white bread, about 40 gms., water or tea without sugar or cream, 
about 400 cc. The bread should be chewed very fine. This breakfast 
is to be removed in just one hour. Usually 30 to 70 cc. are obtained, 
of specific gravity 1012 to 1020. If 200 to 300 cc. are gained, there 
is hypersecretion, motor insufficiency, or perhaps disturbed absorption. 

Riegel' s meal consists of one plate of beef soup, from 150 to 
200 gms. of beefsteak, and 150 gms. of mashed potatoes. It is to be 
removed in from three to four hours. 

Riegel and others have emphasized that a test meal should be one 
to which the patient is accustomed. For this reason, in Germany the 
breakfast consists of bread and tea or water, and the test meal of beef 
etc., since this is a fair sample of the diet to which the German laborer 
is used. Both Ewald and Riegel also insist that the meal should be 



342 



CLIKICAL DIAGNOSIS 



given at that time of the day at which the patient is accustomed to 
ingest a meal of that character. But in this country such meals, particu- 
larly the Ewald breakfast, are not customary, are not in the least like 
ours, and yet American observers quite uniformly use this breakfast, 
overlooking the fact that one cannot test normal physiological 
phenomena with abnormal meals. 

Again, meals should be chosen with reference to the case. Not 
only does the average fare differ in different countries and in different 
grades of society, but the important individual peculiarities of taste 
and habit cannot be totally disregarded. In adopting these two Ger- 
man meals we therefore entirely neglect the two important points, — 
that the meal should be one to which the patient is accustomed, and 
given at the hour at which he is accustomed to take it. It is small 
wonder that many are sceptical as to the value of their use. But the 
work of physiologists (Pawlow) has shown that in the secretion of 
gastric juice the psychical element — that is, the influence of taste, sight 
and smell, etc. — is almost equal to the chemical element, — that is, the 
stimulus from the absorption of soluble products of gastric diges- 
tion, — and since the Ewald breakfast is certainly unpalatable, it is 
perhaps valuable for that reason, since it rules out in some measure 
the former factor, and while to find diminished acidity may not mean 
much, yet hyperacidity does mean that there is certainly some trouble 
present. Many Americans appreciating these facts have attempted to 
introduce meals for American patients. Of course, no two persons' 
tastes are alike, yet we can select as standard a meal more like our 
patients' diet than the above. Fischer's meal is perhaps as good as 
any, which consists of the bread and water of the Ewald breakfast 
plus a quarter of a pound of finely chopped lean beef broiled and 
slightly seasoned. It is to be removed in three hours. 

Fischer has shown by comparing results with his meal with those of the 
Ewald breakfast that those with his are much more constant than with the latter. 
For instance, repeated examinations were made with the Ewald breakfast; in 40 
per cent, of the cases the findings with the later meals were quite different from 
those with the earlier. With his meal there was need of changing the diagnosis in 
but about 8 per cent, of the cases. Using both meals in the same cases, in 67 per 
cent, they gave similar results, 18 per cent, of those showing hyperacidity with the 
Ewald meal showed less with his meal, and in 15 per cent. more. Of the subacidity 
cases with the Ewald, 30 per cent, were normal by his. In various clinics, we have 
noted that several meals were used, the Ewald meal giving some idea of what the 
stomach will do when an indifferent meal is given which excites but little secretion, 
the Riegel indicating the possibilities when there is greater tax upon the secretory 
cells. Some can handle the test breakfast well but cannot the larger meal, while 
others respond well only to the greater stimulus. Fischer gives several points 
which might aid in differential diagnosis based on the use of two meals. Con- 
cerning the diagnosis of the anatomical lesion he says that if the stomach be 
subacid to the breakfast but normal after a proteid meal, we can state that the 
secretory structures are normal, and may suspect that atony with the constant 



THE GASTK1C CO JN TENTS 



343 



presence of food has rendered the mucosa less sensitive ; if subacid to the proteid 
meal as well as to the breakfast, it indicates organic changes ; if subacid to the 
breakfast but hyperacid with a proteid meal, it could mean defective innervation ; 
the same is true if hyperacid to the breakfast and normal to the larger meal ; 
if the hyperacidity of the breakfast continues and increases with the proteid 
meal one may suspect a probable increase of oxyntic cells, since the secretion 
is not in proportion to the stimulus, especially if the secretion continues several 
hours after the meal. If the symptoms and the increased secretion both diminish 
after the meal, disturbed innervation may be suspected. He also emphasizes the 
fact that certain cases of dyspepsia which have been on an almost starvation diet 
for some time need to be fed up pretty well before a test meal is given. This may 
cause a gastric upset, but the flare-up of the condition will be an advantage in 
the diagnosis. 

In all cases we should be sure that the stomach is empty before 
the meal is given. This may be done in the case of the breakfast by 
lavage the preceding night, unless experience teaches us that there 
is in this case no motor insufficiency. The patient should get used to 
the meal and to the tube, and hence the first meal is seldom of any 
value, and the second should be confirmed by at least one other. 
Another point on which sufficient emphasis has never been laid is that 
the meal should be removed at the time of optimum secretion. The 
Ewald test breakfast should not always be removed at the end of 
sixty minutes, nor the Riegel at the end of five hours. With the Ewald 
breakfast, as is easily seen by the study of cases in which meals are 
removed at different intervals, in some cases with rapid motility the 
maximum acidity is attained in forty minutes, in others in an 
hour and a quarter. In either case if the meal be removed at the end 
of just an hour, an erroneous idea will be gained by the low acidities 
found. Another point particularly important in neurotic cases is 
that the time at which the meal is given should be chosen with 
reference to the symptoms, since at other times than during the 
nervous disturbances the gastric condition may be normal. 

Many other meals have been proposed, e.g., the whites of two hard- 
boiled eggs and 100 cc. of water (Jaworski and Gluzinski), and much 
more complicated ones (Pfaundler-Sahli, et ah). We have tried 
nutrose to some extent, in the hope that the pure proteid meal would 
teach more concerning the products of proteid digestion. This meal 
is not at all appetizing, and was given up. 

While it has long been recognized that we were foolishly fitting 
to the American stomach European meals, and need new standards 
following the use of American meals, yet in a general way much has 
been learned from these two meals. 

Acidity of the Gastric Juice. — The fluid removed after the test 
meal or breakfast should be first tested with litmus. This will indi- 
cate acidity in general, which may be due to hydrochloric acid free 
or bound, to organic acids should they be present, and to acid salts. 
In the great majority of cases the litmus will show acid; in a very 



344 



CLINICAL DIAGNOSIS 



few cases the fluid is alkaline. In a recent case of cancer in these 
wards the fresh fluid was alkaline to litmus. It contained man}- pus- 
cells. The next point is the presence of free acid, and Congo red is the 
indicator usually used, indicating free organic or inorganic acid. 

The tests for free hydrochloric acid are all of them color-tests. 
The first and perhaps the commonest used, since it is the easiest, is 
the above-mentioned Congo-red paper. Free hydrochloric acid will 
turn this to a sharp blue, while free organic acids, even in strong con- 
centration, will give a much less definite blue. A trained eye usually 
has no difficulty in recognizing from this test alone whether it be free 
hydrochloric acid or free lactic acid that is present. Acid salts, if 
strong, give a positive test with Congo-red, but they do not occur in 
this concentration in the stomach. 

Methyl violet is the indicator first suggested by V. d. Yelden, who first 
showed the presence of free hydrochloric acid in the gastric juice. 3 This is a very 
satisfactory test. One drop of the saturated aqueous or alcoholic solution of methyl 
violet is mixed with water in a test-tube until the color is a pale violet. This 
is divided in two test-tubes: to the one is added the filtered gastric juice, to 
the other the same amount of water. Free hydrochloric acid will turn the violet 
to a fine blue color. It requires a much larger amount of organic acid. This 
indicates 0.025 P er cent, free hydrochloric acid. 

Tropaeolin OO has been used, but is less sensitive than the above, indicating 
0.03 per cent. In this case the saturated solution is used in the same way as the 
methyl violet. If free hydrochloric acid is present, the yellow is turned to a 
reddish-yellow color. Boas suggests that this be used as a contact test, a few 
drops of the concentrated solution of the stain being warmed in a porcelain dish 
and brought into contact with a small amount of the gastric juice. The dish 
is then warmed over a small flame, and if free hydrochloric acid be present a fine 
violet or true blue color is formed. 

Dimethylamidoazobenzol is most commonly used, and is a very 
sensitive indicator. It gives a pink color with free hydrochloric acid, 
but it reacts also to organic acids and acid phosphates in concentrations 
which might occur in the stomach. 

Gunzberg's solution (Phloroglucin, 2; vanillin, 1; alcohol, 30) 
is the standard test. One or two drops of this solution (which should 
be kept in a tightly corked blue bottle) are warmed on a porcelain dish 
until just dry. One drop of the gastric juice is then allowed to come 
into contact with this and the warming continued. If free acid is 
present, at the edge of contact will appear a beautiful crimson line. 
This was considered very sensitive, showing 0.005 P er cen t. of the free 
hydrochloric acid. Now, some (e.g., Unterberg) says it is less sensi- 
tive than others. It is of value, since it indicates nothing but free 
inorganic acids. The test, although so easy, is often spoiled, since 
the solution is burned by too much heating and a brown non-character- 
istic color apppears. The fluid should not be allowed to get too old. 



3 Deutsch. Arch. f. klin. Med., Bd. 23. 



THE GASTRIC CONTENTS 



345 



It is to be emphasized that the above color-tests are for free hydro- 
chloric acid; that is, for the acid in excess of all acid binding bodies, 
such as proteids, hexone bases, etc. 

Free acid is present in the stomach after a carbohydrate meal in 
from one-half to three-quarters of an hour; after meat, from one to 
one and one-half hours; and after milk and potatoes in three-quarters 
of an hour. 

Total Acidity. — This is the starting-point in all gastric analyses. 
This figure represents the highest amount of hydrochloric acid which 
could possibly be present, and, compared with the amount of free acid, 
gives a good picture of the secretory function and the motility of the 
stomach. 

Acid bodies which could be present are the free and the bound 
hydrochloric acid, other acids, as lactic, butyric, etc., and acid salts. 

To 10 cc. of filtered gastric juice is added an indicator. Tenth- 
normal NaOH is then added from a burette, stirring the fluid all the 
time until the first change of color is seen throughout the whole 
volume. This titration may be done in a porcelain dish, a beaker, or 
an Erlenmeyer flask, the latter two against a white background. 

The indicator usually used is phenolphthalein, two or three drops 
of a 0.5 per cent, alcohol solution. Others have been proposed, among 
them litmus, cochineal, methyl orange. Phenolphthalein is preferred 
because of the sharpness of its reaction, yet it is perhaps the worst 
indicator possible, since this sharp end reaction does not always indi- 
cate the point of neutralization of all the acid elements, especially 
since ammonia is sometimes present in no small amount. The reason 
for its continued use is the desire for comparable results to which an 
empirical value may be given. The same gastric juice will give very 
different results with different indicators, and those with this are too 
high. 

Some use the filtered gastric juice, some the unfiltered, shaking it 
up well to a homogeneous suspension, since the solid particles contain 
relatively more of the acid than the fluid portions. 

Two methods of expression of results are in vogue; the one to 
estimate from the amount of sodium hydroxide used the equivalent 
amount of hydrochloric acid. The number of cubic centimetres of the 
sodium hydroxide used multiplied by 0.00365 gm. equals the amount 
of this acid by weight in 10 cc. In the case of total acidity this would 
be the highest possible amount of hydrochloric acid which could be 
present, hence has the advantage of stating the outer limit of possi- 
bility, although a certain amount of total acidity is surely not due to 
hydrochloric acid. As an exact statement of truth the suggestion of 
Jaworski is usually followed ; that is, the number of cubic centimetres 
of the alkali which would be required to neutralize 100 cc. of the 



346 



CLINICAL DIAGNOSIS 



gastric juice, and to this the term " acidity per cent." is applied. Since 
10 cc. are usually used, the titration figure multiplied by 10 will give 
the acidity per cent, without reference to the acids which may be 
present. 

As illustration: if, using phenolphthalein as indicator, 10 cc. of the juice 
required 8 cc. of tenth-normal NaOH to neutralize the acids present, the acidity 
per cent, would be 8o. Supposing that HC1 were the only acid present, then the 
gastric juice would contain 0.29 per cent. HC1. To avoid confusion, the symbol 
of percentage is never used for " acidity per cent." 

TABLE OF EQUIVALENTS. 
Acidity Gravimetric 
per Cent. per Cent. 

10 0.0365 

14 O.05 

20 O.O73 

2/ O.I 

34 ■ 0.125 

40 / 0.146 

48 0.175 

50 0.182 

55 0.2 

61 0.225 

70 0.25 

73 0.275 

80 0.292 

8 7 0.317 

90 0.329 

95 0.347 

100 • 0.365 

105 0.383 

109 0.4 

Free Hydrochloric Acid, Mintz Method. — Ten cc. of the filtered 

gastric juice are titrated with tenth-normal NaOH until the test for 
free acid is no longer positive. This is based on the supposition that 
the NaOH will neutralize the free before the bound HQ. 

Of indicators there are several. Undoubtedly the most accurate 
is the Giinzberg. As the sodium hydroxide is added, small drops of 
the stirred fluid are removed by a glass rod, or, better still, a platinum 
oesa, and tested on a porcelain dish (see page 344). Fleiner adds 25 
to 30 drops of the Giinzberg reagent directly to the gastric juice, and 
then, as the sodium hydroxide is added, removes small drops which he 
warms in a porcelain spoon. Sahli recommends that the glass rods 
themselves with which the soda is stirred into the gastric juice be 
warmed, since the crimson color can be seen on the rod. He also 
adds from 25 to 30 drops directly to the fluid. In this method a certain 
amount of gastric juice is lost in each of the tests, and hence the 
results should be confirmed by a new portion from which less is re- 
moved. 

A much easier method, and one that is chiefly used in some clinics 



THE GrASTBIC CONTESTS 



347 



in which the best gastric work is done, is to add the sodium hydroxide 
until small drops touched by a rod to Congo-red paper no longer 
turn this blue. Some find approximately the end reaction with 
Congo-red, and then more definitely with the Giinzberg. The Congo- 
red should be used as a paper moistened by drops removed from the 
fluid, rather than added as a solution to the fluid, since with free 
acid results a suspension of a bluish-black precipitate which makes 
the end reaction difficult. As little should be removed as possible for 
each test, and the color produced by the drop controlled by one with 
distilled water. 

Topfer Method. — The method in quite common use in this country, 
since it is the quickest, employs dimethylamidoazobenzol as the indi- 
cator. The smallest drop possible, in fact, a small fraction of a drop 
from the end of a glass rod, is added to the gastric juice, which will 
take a bright red color. The sodium hydroxide is now added until 
the red element of the color is lost. The end reaction requires a 
trained eye, since the transition from bright red to clear yellow is a 
broad one, with the important point the disappearance of the red shade. 

The amounts of free acid determined by these three indicators are 
by no means the same, as the difference sometimes amounts to 100 
per cent. Giinzberg will always be the lowest and dimethylamidoazo- 
benzol usually the highest. Congo-red paper varies very much, some 
qualities giving results almost as low as Giinzberg, some the highest of 
all. 4 

Hydrochloric Acid Deficit. — Tenth-normal HC1 is added to 10 cc. 
of the gastric juice until the test for free acid is positive. The amount 
necessary will depend on the amount of bound HC1 already present, 
the amount of proteid and bases to bind the acid, and the amount of 
alkali secreted, hence a better term suggested by Sahli is the " satura- 
tion deficit." Congo-red paper or Giinzberg can be used, but the 
former is sufficiently delicate. The determination of the HC1 deficit is 
quite as important as of the free acid, since the progress of the case 
either downward or toward improvement can thus be followed. 

For the bound hydrochloric acid Topfer recommends alizarin as 
indicator. This now is little used. 

Fischer. 3 after neutralizing with tenth-normal NaOH for total acidity, then 
adds an amount of tenth-normal HC1 equal to that of the alkali added, and 
then a 4 per cent, calcium phosphotungstate solution to 30 cc. It is allowed to 
stand three to four minutes, animal charcoal added, and filtered. To a measured 
part of the filtrate 6 drops of 1 per cent, rosolic acid are added, stopping at a 
deep orange tint, and its acidity determined. All the proteid has thus been pre- 
cipitated, and the bound HC1 left as CaCL. The total acidity minus that of the 
filtrate equals the combined acid. In case no free acid is present, the deficit is 

4 See Johns Hopkins Hosp. Bull., January, 1903. 

5 Am. Jour. Med. Sci., 1903, vol. exxvi. 



348 



CLINICAL DIAGNOSIS 



first determined, then the total acidity. Enough tenth-normal HC1 is then added 
to raise the total acidity at least 40 per cent, then one precipitates the proteid 
with calcium phosphotungstate and proceeds as above. A simple calculation gives 
the bound acid. 

Total Hydrochloric Acid — Hydrochloric acid is present free, 
bound, and as neutral chlorides. Of the latter we have those from 
the food, those formed in the stomach, and those secreted as such. 

By the total hydrochloric acid is understood the bound and the free 
(" the physiologically active hydrochloric acid"). The Liitke-Martius 
method is one of the simplest for determining this. The principle on 
which this is based is that the difference between the total chlorine 
(= a) and the chlorine after incineration (=b) represents that vola- 
tilized by heat; i.e., the hydrochloric acid. This method has been 
corrected by Reissner, who showed that with the HC1, NH 4 C1 is also 
volatilized. He, therefore, first neutralizes the gastric juice with 
tenth-normal NaOH, using litmus as indicator. This neutralized 
fluid is then ashed and the chlorine determined (=a'). 

a — b = HC1 + NH 4 C1, a — a' = NH 4 C1, a'-—b = HC1. 

The Arnold and Liitke methods are used to determine chlorides. 
(For the solutions necessary, see page 131.) 

Determination of " a." — Ten cc. of the gastric fluid are measured with a 
pipette into a flask with a 100 cc. mark on its neck. Twenty cc. of Solution 1 are 
then added, stirred, and allowed to rest for ten minutes. A few drops of 8 per 
cent. KMn0 4 are then added if necessary to decolorize. The flask is then filled 
with water to the 100 cc. point and the contents well mixed. The fluid is then 
filtered through a dry filter until one-half has passed through. Fifty cc. of the 
filtrate are measured into a beaker and Solution 2 added from a burette till the 
first permanent brown. 

The number of cubic centimetres of Solution 2 necessary to precipitate the 
excess of silver are then multiplied by 2, since but half the fluid was used in this 
titration. This product, subtracted from the amount of AgNOs originally added, 
will give the amount of AgNOs used in precipitating the chlorine. 

Determination of " b." — Ten cc. of the gastric juice are evaporated to dryness 
on a water-bath in a platinum dish. This is then burned over the free flame until 
the ash no longer burns with a luminous flame. It is not brought to a red heat, 
since this would volatilize some of the chlorides. The ash is then rubbed up well 
with water by a glass rod, extracted with about 100 cc. of warm water, brought 
onto the filter and washed until a few drops of the filtrate no longer give a pre- 
cipitate with AgNOs. To the whole filtrate are then added ten cc. of Solution 1, 
and the determination proceeds as for " a." 

Determination of " a'." — -Other ten cc. are first neutralized with tenth-normal 
NaOH, using litmus as indicator, then ashed and the remaining chlorides de- 
termined as for " b." 

(a' — b) 0.0365 gm. = the per cent, of HC1. 

Topfer's Method — This method promised to-be a very simple and 
useful one, since it was purely volumetric and could be finished in a 
very few minutes. The stomach contents were titrated with dimethyl- 
amidoazobenzol for the free hydrochloric acid, and with a 1 per cent, 
aqueous solution of alizarin for the bound hydrochloric acid. This 



THE GASTRIC CONTEXTS 



340 



method received severe criticism at once, since both indicators were 
not above criticism and the end reactions rather doubtful, yet Hari 
in Boas's laboratory found it quite as accurate as some of the more 
elaborate methods if free hydrochloric acid is present; if absent, 
inaccurate. 

Absolute Amount of Hydrochloric Acid Secreted. — It is of course evident 
that the preceding methods give merely percentage values, the percentage of the 
acid in the stomach contents at that time, and without reference to the total 
amount of- acid at other times present. The absolute amount of hydrochloric acid 
at a stated time has been a matter of considerable investigation, especially by 
Bourget and Geigel. 

The last method proposed is the following, the preceding methods being all 
rather tedious. The stomach-tube is introduced and as much of the gastric juice 
expressed as possible. Then 300 cc. of water are allowed to flow in and out of 
the stomach several times. From the difference in the specific gravity of these 
two fractions the amount of undiluted gastric juice in the second fraction can 
be computed. The acid of the first fraction is then determined and that of the sec- 
ond calculated and added to it. This method has some scientific, but no practical 
value, since considerable of the acid secreted has already passed into the intestine. 

Leo's method for total acidity is based on the principle that all acids whether 
free or bound are neutralized by CaCO.s while acid salts and acid binding bodies 
remain unchanged. To 10 cc. of the gastric juice are added 5 cc. of concentric 
CaCla solution (since acid phosphates may be present)-,' and titrated with tenth- 
normal NaOH, using phenolphthalein as the indicator. Let the number of cubic 
centimetres used be "a." 

Fifteen cc. of gastric juice are rubbed up with 1 gm. of pulverized and dry 
CaC0 3 . and filtered through an ash-free filter. Of the filtrate, 10 cc. are freed 
from C0 2 by a stream of air, and then 5 cc. of CaCL solution added, and this fluid 
titrated as above (result = b). 

a — b equals the total acid. If no organic acid be present, this is all HC1. 

The Value of the Tests for Acidity of the Stomach. — Among the 
above tests the simple presence or absence of free hydrochloric acid 
is of the greatest importance, much more so than is its percentage 
amount. Practically every stomach can secrete some acid, but the 
normal stomach will always secrete a physiological excess. It may be 
that the bound acid is alone of value in digestion of proteid, but it is 
the amount free which is the index of the functional ability. The per- 
centage of the free acid is of importance in determining the question 
and grade of hyperacidity, and the deficit to determine the grade of 
the case and to follow it in its improvement. It is to be remembered 
that accurate quantitative work requiring considerable time is not justi- 
fied, for only percentages can be determined, since the total amount can 
never be obtained. The point of departure is the determination of 
total acidity. If the Ewald test breakfast is used the phosphates are 
unimportant, and hence the acidity is the sum of the hydrochloric and 
organic acids. These are never present together free and if free hydro- 
chloric is present the organic acids can be disregarded. Knowing 
these few points, valuable deductions can be drawn. For instance 
(quoting Sahli), if the total acidity be high and no free hydrochloric 



350 



CLINICAL DIAGNOSIS 



present, the acidity is due for the most part to free organic acids. If 
the lactic acid test be good or the odor of the other organic acids 
perceived and many bacteria are present, this diagnosis is confirmed. 
If free hydrochloric is present and the total acidity low, the most will 
be due to hydrochloric acid, and the motility of the stomach may be 
assumed to be good, since the acid binding bodies have passed on into 
the duodenum. If, on the other hand, the total acidity be moderate, 
and free acid small in amount, a poor motility may be assumed, with 
the retention of the products of digestion. 

Physiology of the Gastric Juice. — After the ingestion of a test 
meal secretion of gastric juice begins almost at once. All the hydro- 
chloric acid is at first bound. By the end of a half-hour after the 
test breakfast or two hours after the Riegel meal, as a rule, 
enough has been secreted so that some remains free. The amount of 
acid rises to a maximum, and then as the products of digestion pass 
on into the intestine the acidity begins to fall. One hour after the 
Ewald breakfast the total acidity averages normally 40 to 60 acidity 
per cent., or 0.15 to 0.22 per cent. HC1; over 0.25 per cent, means 
hyperacidity ( some say 0.2 per cent. ) . Lactic acid is not present. Acid 
phosphates are no factor. The free HC1 is from' 20 to 60 acidity per 
cent, or 0.05 to 0.2 per cent. ; the bound from 0.012 to 0.11 per cent. 
Although as a rule there is most in the stomach one hour after the 
meal, yet this will depend on the motility of the stomach. In some 
cases the time to remove the meal is forty minutes and in other cases 
at one and a quarter hours from the time the meal was eaten. It is 
important, therefore, to determine the optimum of each case before 
drawing any conclusions. 

With the Riegel meal the normal total acidity is about 75, but from 
90 to 100 acidity, and free about 44 may be present. 

Diagnostic Value. — Sahli gives the following very valuable 
summary : 

A. There is normal acid secretion: (1) Often in ulcer of the 
stomach and stenosis due to the contraction of its scar; (2) gastric 
neuroses ; and ( 3 ) simple atony. 

B. Hydrochloric acid is increased, that is, the free is more than 0.2 
per cent, and the total is more than 70 acidity per cent, (it may reach 
0.35 per cent, and very rarely 0.8 per cent.) : (1) In the majority of 
cases of ulcer of the stomach; (2) in true continuous hypersecretion 
(but not the hypersecretion due to motor stasis) ; (3) simple hyper- 
acidity and hypersecretion occur only during digestion, at which time 
the per cent, of acid is abnormally high ; (4) paroxysmal hypersecretion 
(gastroxynsis) occurring in neurotic individuals, who, following some 
excitement or other disturbance, vomit large amounts of acid juice ; 
(5) in some cases of chlorosis (in 22 of 30 of Riegel's cases) ; (6) early 



THE GASTEIC CONTENTS 



351 



stages of chronic gastric catarrh; (7) many forms of mental dis- 
orders. 

C. The hydrochloric acid secretion is diminished in ( 1 ) fevers ; 
(2) severe anaemias; (3) the majority of cases of chronic gastric 
catarrh; (4) many gastric disorders due to general neuroses; (5) 
many forms of mental disease; (6) after long standing jaundice; 
(7) ; many chronic cachexias, as tuberculosis of the lung, but not 
always; (8) chronic passive congestion due to heart disease or to 
emphysema, etc.; (9) sometimes in chronic nephritis; (10) after the 
long use of alkaline and saline purges. 

D. Free hydrochloric acid is absent on several examinations (and 
yet the stomach always contains a certain amount of this acid bound) 
in all conditions under C of a severe grade; such as amyloid disease of 
the stomach, toxic gastritis, nervous dyspepsia, phthisis, cardiac dis- 
ease; especially in (1) severe febrile diseases, particularly the infec- 
tions; (2) gastric carcinoma (also other carcinomata) ; (3) atrophic 
gastric catarrh; (4) pernicious anaemia. The most important is 
the failure of free hydrochloric acid in gastric carcinoma. 

And yet gastric analysis is not pure mathematics ; the figures are 
simply relative to the case, some patients being distressed by an acidity 
normal to another man. On the other hand, in all cases the absence of 
free hydrochloric acid is abnormal. 

Standards vary with nationalities, but especially with classes of 
society and still more with individuals. Strauss, at Giessen, thought 
68 a fair average total acidity ; at Berlin, 47. In this country we must 
not try to make German acidities fit any more than the meals producing 
them ; and if possible, every case should be considered individually. 

Among 526 cases of this clinic whose records were studied are the following. 
In all cases the Ewald breakfast was used. 

Pernicious Anemia, 13 cases. Amount removed, 10 to 80 cc. All were 
subacid, the highest total acidity being 38 (acidity per cent.) and below 10 
in 10 cases. In only one was any free hydrochloric present. In two the fluid 
was neutral to litmus ; in one alkaline. Lactic acid was present in two cases (in 
one there was an autopsy, in the other not). In two cases of severe secondary 
ancemia the fluid was only slightly subacid, and free hydrochloric acid was present. 

Malignant Disease not of the Stomach. — Of these, ten were carcinomata, 
four sarcomata. All were subacid (total acidity less than 40). Of the carcinoma 
cases, free hydrochloric was present in seven, absent in two, and the fluid neutral 
to litmus in one. Of the sarcoma cases, in none of the four was free hydrochloric 
present. 

Catarrhal Jaundice, 9 cases. The fluid removed varied from 10 to 86 cc. ; 
total acidity, 10 to 70; in three cases no free hydrochloric acid; in one the fluid 
was alkaline to litmus ; in none was lactic acid found. In a few cases the acidity 
progressively diminished during the course of the disease. 

Cholelithiasis, 14 cases. Amount removed 5 to 120 cc. There was hyperacidity 
in one case (total 79 and 82; free HC1, 42 and 49 respectively on two examina- 
tions). Normal acidity (40 to 70) in six cases; below 40 in six; and in four of 
these no free hydrochloric ; lactic acid in one. 

Cirrhosis of Liver, 6 cases. Normal acidity obtained in one, subacidity in five, 



352 



CLINICAL DIAGNOSIS 



in four of which was no free hydrochloric acid, and one was practically neutral, 
in one, lactic acid. 

Tuberculosis of Lungs, io cases. Normal total acidity in three; subacidity 
in seven ; no free acid in two. Tuberculosis of other organs, five cases ; normal 
acidity in one; no free acid in three; in one of these the fluid was neutral; in 
one lactic acid present. 

Intestinal Troubles. — Diarrhoea, g cases ; in four the acidity was normal ; in 
four subacid, in one almost neutral. In four no free acid was present; in one 
was lactic acid. Constipation, 5 cases, of which two were normal, three subacid, 
one without free hydrochloric. Colitis, 2, both subacid and without free acid, 
and both with lactic acid. Amoebic dysentery, one hyperacid (92 total and 83 free). 

Arteriosclerosis and Cardiac Diseases, 17 cases. Eight normal, six sub- 
normal, three without free acid, and one almost neutral. 

In a group of 36 cases of Miscellaneous diseases, twenty-five showed normal 
gastric conditions. Subacidity without frefe acid was present in cases of heat pros- 
tration, enteroptosis, chronic bronchitis, peripheral neuritis (with lactic acid), 
chronic nephritis, bronchopneumonia, and malaria. 

Various other methods of testing the gastric juice without using 
a tube have been proposed. (The reader is referred to Herschell, 
"Manual of Intragastric Technique," 1903.) 

Dunham advised a thread with a tassel on the end soaked in a 
reagent (as dimethylamidobenzol), which is easily swallowed, the 
thread passing through a glass tube through which the patient drinks 
water, and again easily withdrawn and the color noted. 

Turck's capsule consists of a rubber tube attached to a silk thread, 
and having attached to it various reagent papers. It is enclosed in a 
gelatin capsule. This is swallowed one hour after an Ewald breakfast, 
withdrawn in fifteen minutes, the papers inspected, and a few drops of 
juice in the rubber tube tested and examined microscopically. 

Einhorn's stomach bucket is a small silver bucket holding about 
2 cc, attached to a strong silk, which is easily swallowed and with- 
drawn. 

Pepsin. — We do not think it suitable here to consider the question 
of the nature of pepsin, pseudo-pepsin, etc. The qualitative determina- 
tion of pepsin is less important than that of the hydrochloric acid, 
since pepsin is practically always present when there is any and usually 
when there is no free hydrochloric acid ; that is, the pepsin-forming 
function of the stomach seems more resistant than the hydrochloric 
acid function, and the water secreting function most resistant of all. 
Again, if the gastric juice contains hydrochloric acid, the appearance of 
the contents would indicate at once if pepsin were also present. Its 
determination is, therefore, limited to those cases without the free 
acid, — carcinoma and atrophic gastric catarrh. Scruff found that in 
benign simple hypoacidity and anacidity pepsin does not change much, 
but is considerably diminished in cancer, even when the acid is only 
slightly reduced. This he considers important in the early diagnosis 
of carcinoma. It is absent in atrophic catarrh, gastric carcinoma, and 



THE GASTRIC CONTENTS 



353 



certain cases of pernicious anaemia. Its absence is always a bad prog- 
nostic sign of recovery. 

Qualitative Determination. — The presence of pepsin is assumed if the 
acid gastric juice (HC1 added if none be free) will digest egg albumin 
or fibrin. The fibrin is prepared as follows : Fresh ox-blood is 
whipped and the fibrin kept in running water until perfectly colorless. 
It is then cut in fragments of equal size, put for a few days in alcohol, 
and then for one or two days in cool concentrated neutral carmine 
solution until fully stained. It is then well washed and pressed and 
kept in glycerin stained with carmine. Before use the fibrin is well 
washed with water to remove all glycerin. For egg albumin, the egg 
is boiled until perfectly coagulated (about five minutes) . Long boiling 
should be avoided, since the albumin is made more difficult to digest. 
The white of the egg is then cut into 5 mm. cylinders, using an 
ordinary cork borer, and these into disks 1 mm. thick. These disks 
are kept in glycerin, and also are washed in distilled water before 
using (Sahli). 

To gastric juice is added hydrochloric acid, if necessary, until the 
Congo-red paper shows free acid, then a few fibrin or egg fragments, 
and the whole put in a thermostat. If pepsin is present the fibrin will 
show signs of digestion in from fifteen to thirty minutes, the egg 
albumin in one-half to four hours. If fibrin is used the liberation of 
the carmine is a very early sign of beginning digestion. The first 
Agn for the egg albumin disks is the rounding of the edges. Riegel 
prefers egg albumin to fibrin, since one gets more constant results as 
regards time and it is easier to control the mass used. Sahli recom- 
mends that both be tried since some gastric juices can digest the 
fibrin easily but not the albumin. For a perfect test he recommends 
that five tubes should be prepared for fibrin and five for albumin ; 

Tube 1 : 5 cc. gastric juice plus carmine fibrin. 

Tube 2: 4.5 cc. gastric juice plus 0.5 cc. 2 per cent. HQ and the 
fibrin. 

Tube 3 : 5 cc. gastric juice plus 0.05 gm. pepsin and the fibrin. 

Tube 4: 4.5 cc. gastric juice plus 0.5 cc. 2 per cent. HC1, pepsin 
and the fibrin. 

Tube 5 : 5 cc. gastric juice plus 5 cc. water. 

Tubes 6 to 10 : The same series but using egg albumin. 

Sahli recommends that these tubes be left at room temperature, that 
the difference in them may be more clearly observed. If in tubes 1 and 
6 digestion is present in a half to three-quarters of an hour pepsin is 
normal and the hydrochloric acid normal or increased. The same is 
true if tubes 2 and 3 are not better than 1. Only rarely does one get 
complete digestion without free acid and then it is probable that lactic 
acid acts in its place. But in this case tube 2 will show better digestion. 

23 



354 



CLINICAL DIAGNOSIS 



Very rarely tube 3 is the best ; usually tube 4 is when any pathological 
condition exists. When dilution improves the digestion (and then 5 is 
best) it means that motility is deficient. 

Quantitative Determination. — The general law of ferment action is 
that its activity (as shown by the products of its digestion) varies as 
the square root of the amount of the ferment. The truth of this 
formula has been often tested. Caudet determined the nitrogen of the 
coagulable and uncoagulable proteid by the Kjeldahl method. Schiitz 
and Huppert as the result of very careful work consider the formula 
s = ka ^p.t.s. to hold (k = constant ; s = deuteroalbumose ; a = 
albumin used; p = pepsin; t = time; s = amount of HQ) . 

Hammerschlag used a 1 per cent, albumin solution with 0.4 per 
cent, free HC1 which he put in two tubes, 10 cc. in each. To the one he 
added 5 cc. of water, to the other 5 cc. of gastric juice. These were left 
in the thermostat one hour and the coagulable albumin determined by 
Esbach's tube. Normally, 80 to 95 per cent, of the albumin is digested. 

Mett's Method. — This test has been used by many, 6 and the con- 
clusions were that pepsin varied as much as HC1. But it was soon 
found that the digestive power was decreased in the presence of sodium 
chloride or carbohydrates, or the products of proteid digestion. (This 
inhibition of the ferment is best seen in cancer and chronic catarrhal 
gastritis.) Hence Nierenstein and Schiff advised to always dilute the 
fluid sixteen times, that pepsin in this dilution may obey the formula. 
Egg albumin is filtered and the gas removed by a suction pump for 
several hours. A beaker is filled with the albumin, a bundle of glass 
tubes, each about 10 cm. long and 1 to 2 mm. wide, are then filled with 
the albumin by immersing them in it. Beaker and all are then put for 
five minutes in water at 95 0 C. The tubes are then carefully 
removed, their outside cleaned, and both ends closed with sealing-wax. 
One cc. of the filtered gastric juice is mixed with 15 cc. of twentieth- 
normal HC1 and well shaken. In this fluid the tubes, cut into 2 cm. 
pieces, remain for twenty- four hours in the thermostat. The square 
of the average length multiplied by 16 will give the units of pepsin. 
( By unit is meant the amount of pure pepsin which in twenty-four 
hours will digest an average of 1 mm. of the albumin in the tubes.) 
In these dilutions they found the length of the column digested varied 
from o to 4 mm. The length which theoretically pure pepsin would 
give is 4 mm., yet the undiluted gastric juice often gave from 4 to 6 
and even 8.6 mm. 

Yolhardt digests an HCl-casein solution by, the gastric juice. The 
casein is then precipitated by Xa 2 S0 4 and the filtrate titrated. The 
total acidity will be higher the more the casein is in uncoagulated form 



°E.g., Roth, Zeitschr. f. klin. Med., Bd. 39, p. 1. 



THE GASTRIC CONTENTS 



355 



and the increase in acidity will vary as the square root of the pepsin. 
By this method the least trace of pepsin can be determined. 

Grosse' s Method. — A somewhat similar method was recently proposed by 
Grosse (Bcrl. kl. Wcschr., 1908, vol. 45, p. 643). This test is based on the fact 
that pure casein is precipitated from solution by acetic acid, but the pus ducts of 
its digestion are not. 

One gramme of casein (Caseinum purissimum, Griibler, prepared by Ham- 
marsten's method) and 16 cc. of 25 per cent, hydrochloric acid (specific gravity 
1. 124) are dissolved in one litre of water on the water bath. 

Ten cubic centimetres of this casein-HCl solution are measured into each of a 
series of test tubes. Graded amounts of the gastric juice are added to these tubes, 
the amounts depending on the juice. (Evidently the author dilutes and then adds 
amounts equal to 0.02, 0.03, 0.04, etc., of the juice.) 

These tubes are then placed in the thermostat at 40°C. for just 15 minutes (or 
left in a water bath heated to 40°C.) and then several drops of a concentrated 
solution of sodium acetate added to each. The presence of still undigested casein 
will be demonstrated by a clouding of the fluid. Of the tubes which remain per- 
fectly clear that containing the least amount of gastric juice contains just enough 
pepsin to digest all the casein. 

A unit amount of pepsin is the amount contained in a gastric juice, exactly 
one cubic centimetre of which is sufficient to digest all the casein in 10 cc. of the 
0.1 per cent, solution in just 15 minutes. If 0.025 cc. of the fluid is sufficient it 
would be said to contain 40 units ; if 0.2 cc. is sufficient, 5 units, etc. 

Grosse found that the average number of units for the gastric juice of appar- 
ently normal persons varied from 30 to 50. 

He finds that the Schiitz-Borissow law, Q = V t.p. (Q — amount of casein 
digested; t = time ; p = amount of pepsin) not to be true; but that Q — t.p. That 
is, double the amount of pepsin and you double its digestive action. 

The Fat-Splitting Ferment. — Volhardfs Method.— The yolk of 
0116 egg is mixed with 30 to 40 cc. of water; 10 cc. of this mixture are 
mixed with the gastric juice, both fluids being warmed separately in the 
thermostat, and then the mixture placed in a thermostat at from 37 0 to 
40 0 C, then cooled. Seventy-five cc. of ether and a few cubic centi- 
metres of alcohol are then added and the whole shaken out. A meas- 
ured amount of this fat-containing ether is mixed with 50 cc. of neu- 
tral alcohol and titrated with tenth-normal NaOH, phenolphthalein 
as indicator. The result is the fatty acid. To the titrated mixture 
are now added 10 cc. of tenth-normal NaOH and placed on a water- 
bath for two hours. The flask is connected with a condenser and a 
calcium oxide tube to exclude C0 2 , or is allowed to stand for twenty- 
four hours in a closed flask at room temperature. This is to saponify 
the unsplit fat. Ten cc. of tenth-normal HQ are now added to free the 
fatty acid and the mixture again titrated with tenth-normal NaOH, 
phenolphthalein as indicator, to determine the fat which had been un- 
changed in the thermostat. From the relation of these the percentage 
of split fat is reckoned, and hence the number of units of ferment 
present. This ferment is very sensitive to alkali. It has been shown 
that its activity varies as the square root of the amount of the enzyme. 
Stade's formula is: p=*\jfX-\Jt in which p equals the products 
of digestion, f the units of ferment, and t the time. If f represent the 

7 Munch. Med. Wochenschr., 1000, v. and vi. ; Zeitschr. f. klin. Med., Bd. 42 
and 43. 



356 



CLINICAL DIAGNOSIS 



amount of ferment which will digest i per cent, in one hour, then if in 
three hours 6 per cent, of the fat be found split, twelve units of ferment 
were present. 

It has been found that in hypochylia and achylia this ferment is 
absent or diminished. Riegel considers that much of the former work 
which has been spent on hydrochloric acid should now be spent on fer- 
ment action. It is needless to say that the demonstration of this fat- 
splitting ferment throws considerable disrepute on those test meals of 
neutral fats which have been proposed. Volhardt considers that in 
two hours from 30 to 36 per cent, of the fat is split. These fatty acids 
dissolve in the bile and aid in the emulsion of the neutral fat. Hence 
the stomach really does considerable of the work of the pancreas. 

Rennet. — The presence of rennet is proved by the coagulation of 
milk by the neutralized gastric juice. Leo's method is as follows: 
From 5 to 10 cc. of milk and 3 to 5 drops of gastric juice are placed in 
the thermostat. A better method (Riegel) is the mixture of from 5 to 
10 cc. of gastric juice neutralized with tenth-normal NaOH and 5 to 
10 cc. of fresh milk. Normally, this will coagulate in from ten to fif- 
teen minutes. If slower, lactic acid formation must be excluded. The 
reaction is unchanged by the ferment. The presence of the zymo- 
gen in the absence of the ferment has been much disputed. As a rule, 
this ferment varies with pepsin, but it is easier to test for. 

Boas attempted quantitative determination by mixing variously 
diluted neutralized gastric juice with an equal amount of milk until no 
coagulation occurred. Normally this would cease at a dilution of from 
1 : 100 to 150; in severe cases, however, when the dilution was only 
from 1 : 5 to 10. 

The practical importance of the quantitative determination of this 
ferment is uncertain, since the methods are not good enough. Glassner 
considers that it has diagnostic value ; for instance, that in pyloric 
cancer this ferment is uninjured. If the pepsin and the rennet are both 
much diminished he considers we have a tumor of the fundus ; if the 
pepsin is diminished and the rennet good, one of the pylorus. 

The extent of gastric digestion is considered by some important. 
J. Miiller fed a patient from 1 to 200 gms. of finely ground meat and 
found that in one hour 28 per cent, of the albumin was dissolved. 
This is a minimal amount, since some has passed to the intestine. In 
supersecretion and hyperacidity the albumin digestion was much in- 
creased, especially if at the same time there was pyloric stenosis. But 
in subaciditv, chronic gastritis, cancer of the stomach, it was much 
diminished. 

Benedict 8 has given a simple method of determining the products 
of digestion. The albumin is precipitated by heat, the albumoses by 
s Am. Jour. Med. Sci., 1904, vol. cxxvii. 



THE GASTRIC CONTENTS 



357 



ammonium sulphate and the peptone by phosphotungstic acid. The 
various precipitates are determined volumetrically by centrifugalizing 
them to the smallest volume. 

The Products of Albumin Digestion. — One may determine this if 
he will, and yet from the practical point of view it is of little im- 
portance. From a theoretical point of view it is interesting to note that 
in cases of carcinoma of the stomach digestion of proteid is so much 
more rapid than normally that it is safe to conclude that an abnormal 
ferment is present. 9 This is rendered very probable, since artificial 
digestion experiments with the heated and unheated carcinoma tissue 
show a similar relation. 

In our benign cases tested in this way, the Ewald breakfast being 
used, the average amount of nitrogen in albumose form was 51.7 per 
cent.; in the phosphotungstic acid precipitate, 31.4 per cent.; in the 
residue, 16.9 per cent. In the carcinoma cases these figures were re- 
spectively 27.5, 47, and 27.6 per cent. 

Starch Digestion. — It has recently been again emphasized 10 that 
the saliva is not as unimportant in starch digestion as was formerly 
supposed, and that it renders soluble in the stomach from 50 to 70 per 
cent, of the starch, thus relegating the starch digesting function of 
the pancreas to a subordinate position. This digestion occurs, how- 
ever, before total hydrochloric acid has reached 0.12 per cent., hence is 
inhibited in cases of hypersecretion and hyperacidity. Concentrated 
lactic acid also can inhibit this process. 

The stages of starch digestion are soluble starch, erythrodextrin, achroodex- 
trin, and maltose. The relative amount of this may be approximately detected- 
by the use of a very weak Lugol solution, since the later products of starch 
digestion have a greater affinity for the iodine than have the earlier. The colors 
obtained vary from blue to colorless, the first blue-violet, the erythrodextrin red 
to mahogany-brown. One drop of the weak Lugol's added to a small amount of 
gastric juice will therefore give no blue color with starch if much achroodextrin 
be present. On the other hand, if very few of the higher products be present, 
it will give a distinct blue color. From the number of drops to be added 
before the blue color appears may therefore be approximately determined the 
relative extent of the starch digestion. This has been considered a good indica- 
tion of the amount of free acid, since in cases with high acidity the first drop 
may give the end reaction. And yet it should be remembered that the saliva is 
also to be taken into consideration ; that of smokers, for instance, is supposed 
to have less digestive power than normal. 

Lactic Acid. — The test for lactic acid is of value only when it is 
known that the meal contained none, and that if any is formed from, 
any constituent of the meal it would normally have disappeared at: 
the time of the test. Riegel says its presence in the stomach is never' 
normal except during sugar digestion. One usually tests the juice 

9 Deutsch. Arch. f. klin. Med., vol. lxxii. p. 415. 

10 J. Miiller, Verh. d. XIX. Congr. f. inn. Med. 



35S 



CLINICAL DIAGNOSIS 



/ 



eem 



after an Ewald breakfast, but this is hardly fair (see page 379). Dock 
uses a shredded wheat biscuit. 

Some breads contain lactic acid, hence Boas proposes a meal of 
one tablespoonful of oatmeal cooked in one litre of water with a little 
salt. The stomach is well washed out and this meal given in the even- 
ing and removed the following morning. It is said that normal saliva 

, , can produce lactic acid from this meal. This meal 

is little used. 

Uffelmann's test is the one in common use. This 
solution is always made up fresh. To about 20 cc. 
of 1 per cent, carbolic acid in a test-tube is added 
one drop of 10 per cent. Fe 2 Cl 6 . A deep amethyst 
color is produced. This is diluted with distilled 
water until the fluid is fairly transparent. It is 
then halved. To the one test-tube is added a drop 
or so of the gastric juice, to another the same 
amount of distilled water. If lactic acid be present, 
in the former the fluid takes a definite yellow or 
yellowish-green (canary-green) color. 

Others propose 10 cc. of a 4 per cent, carbolic acid in 
20 cc. of distilled water and one drop of the ferric chloride ; 
others one drop of the ferric chloride solution diluted with dis- 
tilled water until almost colorless, and then the carbolic acid 
(2 to 4 per cent.) added until the proper color is produced. 

It should be noted that decolorization alone is 
not sufficient. A definite canary color or yellow is 
necessary. The blue is merely for contrast, hence 
one may dispense with the carbolic acid. It is well 
to control the test with dilute lactic acid. 

The test as given by Strauss is particularly valu- 
able. In a small separating funnel (see Fig. 63) 
with two marks, one indicating 5 and the other 
25 cc, are introduced 5 cc. of the gastric juice. 
The funnel is then filled to the 25 cc. mark with 
alcohol-free ether and well shaken to extract the 
lactic acid. One drop of hydrochloric acid may 
be added to liberate that lactic acid which is bound 
to proteid. The gastric juice is then allowed to run 
out and 5 cc. of distilled water added, then 2 drops ( from a medicine 
dropper to insure uniform size) of a 1 per cent. Fe 2 Cl 6 solution. If 
o. 1 per cent, of lactic acid be present, the water layer will take a definite 
canary-green color. This test is perhaps not as delicate as some others, 
but it may be said confidently that if positive a pathological amount of 
lactic acid is present. Always to extract with ether is quite necessary, 




Fig. 63. — Strauss' sep- 
arating funnel for lactic 
acid tests. 



THE GASTRIC CONTENTS 



359 



since simple decolorization or even a suspicious color may be given by- 
sugar, proteid, and alcohol, and by some other inorganic acids (oxalic, 
citric, tartaric), and positive tests may be prevented if much phosphates 
or peptones are present. Again, ferric chloride may give a cloud in the 
gastric juice which will obscure the test. If, however, the result of an 
Ewald breakfast given on a clean stomach be examined, trouble from 
these sources will not occur. 

This test has been further modified. Kelling 11 dilutes the fluid with twenty 
volumes of water and then adds one or two drops of 5 per cent. Fe 2 Cle. The tube 
is then sighted by transmitted light, and it is stated that from it 1 of lactic acid 
in 10,000 to 15,000 of water can be detected. Knapp 12 adds 1 cc. of gastric juice 
to 5 cc. of ether and shakes. He then superimposes this extract upon a colorless 
ferric chloride solution (1:2000) freshly prepared, and gets a canary-colored ring. 

De Jong 13 adds to 5 cc. of the gastric juice one or two drops of HC1. He 
evaporates this to a syrup over a free flame and then extracts the residue with 
a little ether. The volume is then made up to 5 cc. with distilled water and one 
drop of 5 per cent. Fe 2 Cl6 added, and the whole well shaken. A definite green 
color is produced by 0.05 per cent, lactic acid. 

Quantitative Lactic Acid. — For clinical purposes the Strauss modifica- 
tion of the Uffelmann's method is accurate enough, and perhaps of 
greater value than the more accurate methods, which might show 
small amounts normally present. It is only the pathological amounts 
that are of value. The Hehner-Maly method is satisfactory if one con- 
sents to consider all organic acids as lactic. 

Some idea of the amount may be obtained by comparing the acidity 
of the gastric juice before and after extracting it with ether. 

Boas Method. — The principle of this method is to oxidize lactic acid to alde- 
hyde and formic acid. The aldehyde is then changed to iodoform and this de- 
termined. 

Either 10 or 20 cc. of the filtered gastric juice in a porcelain dish are evap- 
orated to a syrup on the water-bath. If free HC1 be present, BaCOa is added in 
excess to prevent its volatilization. To the syrup a few drops of phosphoric acid are 
then added to again set the acid free and then the syrup heated to drive off the 
CO2. It is then cooled and extracted two or three times with 50 cc. of ether. 
After standing about half an hour the ether is poured off, evaporated to a residue, 
this taken up with 45 cc. of water in a flask, then shaken and filtered. To the 
filtrate are added 5 cc. of concentrated H2SO4 (sp. gr. 1.84) and a knife-point 
of manganese. This flask is then fitted to a distilling apparatus with two tubes 
through its cork, the one for the cooler and the other for the clamped rubber 
tube through which air may later be blown in order to cleanse the cooling tube 
from the aldehyde, and the fluid distilled until about four-fifths has passed over. 
The other end of the cooling tube dips into a well-closed Erlenmeyer flask con- 
taining 10 to 20 cc. of tenth-normal iodine solution in 20 cc. of KOH. This is 
shaken, closed tightly, and allowed to stand for a few minutes. The aldehyde 
will be changed to iodoform. To it are then added 20 cc. of HC1 (sp. gr. 1.018) 
and an excess of sodium bicarbonate. It is then titrated with a tenth-normal 
sodium arsenite or tenth-normal thiosulphate solution, which has been accurately 

" Zeitschr. f. physiol. Chemie, 1903. 
12 New York Med. Jour., August, 1901. 
13 Arch. f. Verdauungskranheiten, Bd. 2. 



360 



CLINICAL DIAGNOSIS 



standardized to the tenth-normal iodine solution, until decolorized. A little fresh 
starch solution is then added, and one titrates back to the first permanent blue. 
The amount of iodine solution less that of the tenth-normal thiosulphate solution 
gives the amount of the former necessary to form the iodoform. One cubic 
centimetre of the iodine solution equals 0.003388 gm. of lactic acid. Or the 
iodoform may be estimated gravimetrically (see page 195). 

Other Organic Acids. — Acetic, butyric, and valeric acids occur and 
are recognized by their odor. They are the result of bacterial decom- 
position, although the reason why in some cases one, in some another, 
is formed is not known. For instance, in a recent case the patient after 
an Ewald test meal complained of the taste of vinegar and the gastric 
contents were found rich in acetic acid. This man had given all the 
symptoms of hyperacidity. 

Much organic acid could come from the foods, from fermentative 
processes in the stomach, or from the action of the fat-splitting fer- 
ment. 

On a lactic acid-free meal, and only such should be used, one 
should normally find no lactic acid in the stomach. Lactic-acid-pro- 
ducing bacteria are in the mouth, but should not have enough time to 
produce the acid in the stomach. 

Acetic acid carefully neutralized with soda is tested with 1 or 2 drops of 
Fe-Cle solution, which gives the bluish-red color of ferri-c acetate. 

Butyric acid in the presence of fine fragments of CaCl 2 separates in fine oily 
droplets. 

Total Organic Acid. Hehner-Maly Method. — The principle of 
this method, which has been recommended by many, is that if a mix- 
ture of organic and inorganic acids be ashed the inorganic salts will re- 
main neutral, while the organic will be changed to alkaline-reacting 
carbonates. The original acidity minus the final alkalinity may be 
considered to equal the mineral acidity. 

Ten cc. of filtered gastric juice are neutralized with tenth-normal 
NaOH, using phenolphthalein as an indicator (number necessary=a). 
This fluid is then evaporated and ashed, the ash taken up with water 
and titrated with tenth-normal HC1, phenolphthalein again used as 
indicator (amount necessary =b) a — b = the mineral acidity. 

The method is easy. By it the acid phosphates are included with 
HQ, hence in its original purpose as a method of determining HC1 the 
phosphates must be separately determined : but it is the easiest method 
to determine the organic acids. 

Bases of the Gastric Juice. — Of these sodium is the most important. 
V. Mehring has shown that the stomach can and does secrete sodium 
carbonate to control the amount of hydrochloric acid. Reissner 
showed an increased secretion of alkali in cancer. 

A base present in no small amount is ammonia (normally 0.1 to 



THE GASTRIC CONTESTS 



301 



0.15 p. M.). The gastric wall is the tissue of the body richest in this 
base. This amount of ammonia in the gastric contents throws great 
doubt on the value of the titration with phenolphthalein as indicator. 
The source of the ammonia is doubtful, some even say all is from the 
saliva. 

Fermentation. — Fermentation with gas formation occurs in dilata- 
tion of the stomach even in the presence of free HC1 in case the stasis 
be sufficient, never when motility is normal ; more rarely in diminished 
or an-aciclity, in which case lactic acid formation is more common. 
The fresh gastric juice or vomitus unfiltered is well shaken, and poured 
into two fermentation tubes, the second as a control to which is added 
a small amount of glucose, since all of the carbohydrate may have 
already been fermented. If there is no gas in twenty-four hours it is 
advised to wait from three to four days. The chemical analysis of 
the gas is not very important. This test is important in determining 
the degree of stagnation, although fermentation without gas produc- 
tion does occur, and there is a small amount of gas formed in the normal 
stomach when much food is ingested, or when there are clefts or 
pockets in the stomach wall. 

A great many different organisms have been isolated and studied, 14 
among them yeasts and sarcinae in those cases with free acid, and long 
bacilli in cases of cancer. Sarcinae are usually present when there is high 
acidity. "If there be slight total acidity and sarcinae the evidence is for 
cancer. High total acidity with short bacilli speaks against cancer; 
while low total acidity with many long bacilli, in favor." As products 
of such fermentation may be mentioned alcohol, methane, ethylene. 
Sarcinae alone have been found to produce ethyl alcohol, aldehyde, 
acetic and formic acid, but not lactic nor butyric, nor carbon dioxide 
nor hydrogen. Coyon considered that the sarcinae have little ferment- 
ing power, and isolated two bacilli, — the enterococcus. which produces 
lactic acid, acetic acid, and ammonia bodies from proteid, lactic and 
acetic acids from carbohydrates ; and Coccus radiaire, which from 
albumin builds fatty acids. Yeasts are common, producing carbon 
dioxide, alcohol, aldehyde, and acetic acid from carbohydrates, and 
hydrogen disulphide and ammonia compounds from albumin (Groot). 

Hydrogen disulphide from decomposing proteid is rare in cancer 
but quite common in benign gastric dilatation, and may be detected 
by its odor or by suspending over the fluid a paper wet with alkaline 
sugar of lead. Dauber found in nearly every stomach bacteria which 
can produce this gas from sulphur bodies, and, in fact, given long 
enough time, nearly all bacteria can do this, hence there is nothing 
specific in its presence in the stomach. But it cannot be produced if 
there is free hydrochloric acid present. On the other hand, that from 

14 See Ehret, Mittheil. aus der Grenzgeb. d. Med. u. Chir., Bd. iii. Heft 5.- 



3G2 



CLINICAL DIAGNOSIS 



the food must always be excluded ; for instance, from radishes, onions, 
and also from the saliva. 

Microscopical Examination. — This is seldom of much value since 
a large amount of unchanged starch granules and muscle-fibres pass 
to the intestine. In cases with poor gastric secretion the muscle-fibres 
are particularly well preserved with their cross striation, but if there 
is much stasis even this is no sign. Mucus may be recognized from its 
fibrillar character and the cells that are embedded in it, also by staining 
it with safranin or Ehrlich's triple stain. 

Pus is very rarely found macroscopically. It might be expected 
in gastritis phlegmonosa, in abscess of the stomach, and in rupture of 
one through the stomach, especially a subphrenic abscess. Strauss 15 
has also found it in a case of cancer of the fundus and lesser curvature, 
with subphrenic abscess, in amounts from 60 to 500 cc. Large num- 
bers of pus-cells may be found in cancer of the stomach, and we had 
one case in which much was present microscopically, yet its diagnostic 
value is to be doubted. Microscopically, a few pus-cells are always 
found in the wash-water of an empty normal stomach. The fasting 
stomach should be examined, since when mixed with food the cells 
cannot be recognized; also it is seen best in stomachs with good 
motility. 

Fragments of mucosa are often torn loose during lavage without 
any bad result following. This is particularly true if suction with a 
pump or Politzer bulb be made. Yet if the tube be carefully used their 
presence may in a general way indicate the vulnerability of the mucosa. 
Some of these fragments from the proliferating mucosa, in cases of 
achylia gastrica, will give a very good picture of carcinoma. The morn- 
ing lavage of the stomach may show many of these fragments, and then 
is the time when it is suggested to search for fragments of tumors. In 
a reported case of Heynoch's purpura such fragments of mucosa were 
found in the washings ; the wall of the stomach was quite cedematous 
(Dr. Morris). In the fasting stomach also may be found character- 
istically shaped groups of nuclei of leucocytes whose protoplasm has 
been digested. In the fasting stomach also may be seen myelin 
masses, altered by HC1, which have the appearance of snail-like 
spirals. Crystals are also present, especially if bile be mixed, of 
cholesterin, leucin, calcium oxalate, and triple phosphate. In conclu- 
sion, the microscopical examination is interesting rather than impor- 
tant. Of greatest importance are fragments of carcinoma. Many 
yeasts, especially if they occur in chains, sarcinse, and long bacilli, are 
also important. 

Infusoria are sometimes present (see page 405) in the gastric 
juice, the reaction of which must be neutral or alkaline. 

15 Berl. klin. Wochenschr.. 1899, No. 40. 



THE GASTRIC CONTENTS 



363 



The greatest variety of bacilli are of course found. Epithelial 
cells occur often in abundance, particularly when digestion is poor. 
Cancer fragments are very rare. If free hydrochloric acid be 
present, moulds and yeasts and sarcin.e will predominate; if none, 
bacteria. Einhorn found in the wash-water spores of moulds which 
he thought lodged in crevices of the mucosa and might aid in the 
hyperacidity and the gastralgia. Yeasts are abundant in gastric dila- 
tation, and a few may be found in normal stomachs. Sarcinae occur 
in large numbers in benign dilatation, occasionally in gastritis, ulcer, 
and neuroses, but rarely in cancer. One observer reports them in such 
numbers as to form plugs obstructing the pylorus. Ehret found many 
sarcinae in cases of intense fermentation, but neither yeasts nor bacteria, 
and considers that they indicate a severe stasis. He does not consider 
that they occur only with free hydrochloric acid. Two sizes may be 
found, the large and the small. In a recent case in this clinic with 
dilated stomach the sarcinae were in great numbers, and of huge size. 

Blood. — The oesophagus, nose, mouth, and lung as a source must 
be excluded. Small amounts of blood have no significance, since slight 
lesions of the pharynx, oesophagus, or stomach are very easily produced 
in vomiting or by the tube. Blood may be present in large amounts 
in ulcer of the stomach or in rupture of venous dilatations at the cardiac 
orifice as in liver disease. In case the stomach be empty, the blood 
will then be arterial, but as a rule it is dark because of the haematin 
produced by the gastric juice, and is clotted and well mixed with food. 
In carcinoma of the stomach there is usually a slight constant oozing 
from the tumor. This blood is well mixed with the food, digested, and 
looks like coffee-grounds. This is a very valuable sign in cases of 
gastric dilatations and indicates- cancer of the mucosa. It also occurs 
in hyperacidity with hemorrhagic erosions of the mucosa. The detec- 
tion of this small amount of blood is no easy matter, since microscop- 
ically nothing is found. Blood may arise from tuberculous ulcers ; 
from slight injuries to the mucosa ; from small aneurisms of the gastric 
arteries ; and from the digestion of the mucosa over an infarcted area. 
Gastric hemorrhage occurs in chronic passive congestion ; cirrhosis of 
the liver ; various constitutional diseases without apparent reason, as in 
anaemias, haemophilia, Hodgkin's disease ; in active hyperaemia as in 
vicarious menstruation; and following abdominal operations, espe- 
cially such as involve the omentum, in which case they are a disturbing 
symptom, but of no moment. All the blood of even a profuse hemor- 
rhage may pass by the stools, 

Occult hemorrhage discovered by examining the gastric contents 
and stools occurs in several conditions. Boas and Kochmann 16 divide 
cases as follows : Those with no hemorrhage : gastritis anacida, sub- 

16 Arch. f. Verdammgsk.. 1902, vol. viii. Heft I, 2. 



304 



CLINICAL DIAGNOSIS 



acidity, hypersecretion, benign ectasis: cases with blood at times, 
especially ulcer ; cases with blood as a rule, especially cancer. 

Deen's Test. — To the gastric juice is added I cc. of fresh tincture 
of guaiac and I cc. of Hiihnerf eld's solution (glacial acetic acid, 2; 
distilled water, 1 ; oil of turpentine and alcohol, of each, 100 cc). The 
mixture is well shaken. If blood is present the fluid turns blue. The test 
is also given if iron compounds are present, or some vegetables, etc.. 
hence it has chiefly a negative value. Weber's modification is recom- 
mended by Riegel : to the gastric contents is added one- third volume 
of glacial acetic acid and it then shaken out with ether. After the ether 
extract has cleared, to a few cubic centimetres are added 10 drops 
of guaiac tincture and 20 to 30 drops of turpentine. Blood will give a 
bluish-violet color. In this case only raw or rare-cooked meat is to 
be excluded. 

Heller's test is also used, but various red substances must be 
excluded, coffee, cocoa, wines, etc. The precipitate should be collected 
on a filter and dissolved in acetic acid. Rhubarb, senna, and santonin 
may deceive. 

For the spectroscopic test the gastric contents are diluted with 
water, a few drops of concentrated acetic acid added, and then shaken 
out with one-fifth volume of ether. In a few minutes a clear layer of 
brown ether solution of haematin is obtained. The four-band spectrum 
of haematin in acetic acid could be due to chlorophyll, hence alcoholic 
KOH is added and it reduced with (NH 4 ) 2 S, the red fluid will now 
give the two-line spectrum of reduced haematin. 

Absorption Power of the Stomach. — Although this function of 
the stomach may not be important, yet there are certain substances 
which are absorbed, as alcohol, sugar, dextrin, peptone, albumoses, 
et al., and in amounts varying with the quantity in the stomach. The 
absorption test generally applied is that of Penzoldt. On an empty 
stomach is given a gelatin capsule containing 0.2 gm. of potassium 
iodide. The saliva and urine are examined every few minutes until 
the test is positive. To the saliva or the urine are added a little starch 
meal and fuming HC1. The blue color will indicate the presence of 
iodine. Or a little starch meal is added and crude HN0 3 , but an 
excess of acid must be avoided or the first trace of iodine will be lost. 
Also the sputum and starch must not be left in contact long as the 
digestion will give erythrodextrin and achroodextrin. Chloroform 
may be used instead of starch, and will take up the iodine to a pink 
solution. Normally the excretion begins in six and one-half to fifteen 
minutes in the sputum, and in the urine in thirteen and one-half 
minutes. The time is shortest on an empty- stomach and at the height 
of digestion. The test should be used under constant conditions, 
hence Sahli combines it with the Ewald breakfast, in which case 



THE GASTKIC CONTENTS 



365 



iodine appears in five to twenty-five minutes. The test has a theoret- 
ical, but very little practical value. Only a considerable delay counts. 
There is a delay in most gastric diseases. This may occur in dilata- 
tion with considerable catarrh, and carcinoma ; there is no delay in 
ulcer without catarrh, nor in neurotic disturbances. Potassium iodide 
is not food, and it is not absorbed from a stomach which is closed 
off from the intestine, hence the test may show when it first reaches 
the intestine. 

Again, of importance is the secretion of water, which is the 
most resistant function of the gastric mucosa and may be stimulated 
independently of the other secretory functions. It is increased owing 
to the presence and absorption of alcohol, sugars, etc. This " dilution 
secretion " is supposed to be a measure to protect the intestine, the 
increased fluid diluting the gastric contents. 

Motility of the Stomach. — It is to be emphasized that disturbance 
of the motility of the stomach is far more important than disturbance 
of its secretions. If motility be good the intestine can vicariously 
make up easily for any insufficiency on the part of gastric secretion, 
and the person live years in ignorance of the fact that he has no gastric 
juice. But if motility be impaired the stagnation of food in the dilated 
stomach soon and always produces serious results. 

Hypermotility is seen especially in cases of hyperacidity, and it may 
be necessary to remove the Ewald breakfast in from one-half to three- 
quarters of an hour in order to obtain any fluid. But the most rapid 
motility is seen in cases of jejunal fistula high up. In these cases of 
starvation the stomach seems to try to hurry the food into the intestine 
at as rapid a rate as possible. In one such case a glass of milk was 
drunk and collected at the fistula. It appeared in one minute, and was 
wholly recovered in four minutes from the time it was swallowed. The 
surgeons used the following method of determining the position of the 
fistula. An oyster was tied with a piece of silk thread and swallowed. 
In a few minutes it appeared at the abdominal opening. The thread 
was then cut at the teeth, pulled through and measured. 

It is quite important to wash the stomach out to be sure it is 
empty, since in cases of achylia the tube may siphon nothing, but the 
wash-water may show considerable solid matter. 

Megalogastria means enlargement of the stomach, and may or not 
be accompanied by motor insufficiency. 

Ectasis refers to enlargement with motor insufficiency; it is 
"atony" if due to real weakness of the muscle wall, is . " hypertonic 
ectasis" when due to pyloric stenosis. 

Motor insufficiency may be absolute or relative and dilatation of 
the stomach is in general- due to one of two factors, — (i) atony of 
the gastric wall, in which case the muscle is not strong enough to 



366 



CLINICAL DIAGNOSIS 



empty the stomach ; in this group are found the largest stomachs. 
Strauss reports a case 17 of five and a half liters capacity. 
(2) Muscular insufficiency, that is, an obstruction at the pylorus 
which renders exit of the food difficult. In such a case the muscle 
wall may be abnormally strong and hypertrophied ; in others there is 
no dilatation of the stomach, since the wall is extensively infiltrated. 

Stenosis at the pylorus causing dilatation may be congenital or 
acquired. Acquired stenosis may be due to the contraction of scars 
of ulcers ; to cancers ; to hypertrophic stenosis which is said to be the 
result of continued pyloric spasm stimulated by hyperacid gastric juice 
or an ulcer ; to the scars resulting from irritating poisons ; to the 
pressure of neighboring tumors ; to twists ; to diverticula ; and, finallv, 
to malpositions of the pylorus resulting from adhesions. 

In a normal case, no matter how large the meal, the stomach should 
be empty in seven hours. A common test of motility is to give without 
previous lavage a simple evening meal but one of constant composition, 
as of cold meat, bread and butter, and tea (Boas). If the following 
morning food be found, there is considerable motor insufficiency. 
If before this evening meal the stomach had been well washed out and 
found empty in the morning, the degree of insufficiency is less ; if food is 
found, even more. If the stomach contains food seven hours after a 
full noon or morning meal, but none after a night's rest, the degree 
of insufficiency is least. 

Ewald and Strauss have recommended to give one spoonful of 
currant or raisin preserve with the evening meal. The seeds of this 
can be recognized in the stomach washings the next morning, no 
matter if the patient has taken a large breakfast. 

If in the morning the fasting stomach contain over 100 cc. of 
fluid, motor insufficiency may be suspected, but such a stomach will be 
empty in the morning if the evening before it had been washed clean. 

The symptoms of dilatation are those of the disease causing it, 
and the vomiting of large amounts of food which has been eaten 
more than seven hours, in some cases even three days, before. The 
vomiting of food in the morning before breakfast is a sure sign. 

To please those patients who object strenuously to a stomach-tube the follow- 
ing method of Ewald and Sievers is used. It is based on the belief that salol 
remains unchanged in the stomach, but is split by the pancreatic juice and bac- 
teria to salicylic acid and phenol. The salicylic acid is excreted in the urine as 
salicyluric acid, which may be easily detected by the violet color on the addition 
of ferric chloride to the urine. The test assumes that the time of splitting, 
absorption, and excretion remains constant, which is 1 not always true. One 
gramme of salol is given with the test breakfast and the urine is examined at 
intervals. The test should appear in the urine at the latest in seventy-five minutes. 

17 Deutsch. med. Wochenschr., 1904, No. 15. 



THE GASTBIC CONTEXTS 



367 



If the first appearance is delayed longer there is certainly motor insufficiency. 
But one cannot be sure that the salol will mix with the food in the stomach. 
It may enter the intestine with the first portions of food or with the last. Again, 
in cases of stagnation of the stomach contents, bacteria can split some of the salol, 
and mucus will also, so Huber recommends to test not the time of the appearance 
but of the disappearance of the salicyluric acid. Its output should cease in from 
twenty-six to twenty-seven hours. The urine is therefore examined first tweiity- 
seven hours after the meal, and if found, at intervals of three hours. Sahli 
recommends to determine the time both of its appearance and disappearance. 
While this is a very gross test, it does give a certain amount of information. In 
cases with disturbed motility, especially in those with simple atony and pyloric 
stenosis, the test may not appear for several hours, and may continue for even 
forty hours. 

Jodipin has also been recommended by Winternitz. 18 Pancreatic secretion and 
the bile are necessary to split iodine from this fatty compound. 

To determine the amount of residue in the stomach various methods have 
been proposed, such as the introduction of 100 gms. of olive oil (Klemperer) and 
the removal of as much as possible in two hours, washing well with water and 
separating the oil in a separating funnel. This method is severely criticised 
since the oil does not mix uniformly with the contents. 

Sorensen and Brandenburg 19 recommend to give on the empty stomach 300 
to 500 cc. of 3 per cent, protogen. Of this there is removed as much as possible 
in from one-half to one hour. From 100 to 200 cc. of water are then introduced 
and again removed. The nitrogen in both fractions is determined by the Kjeldahl 
method, and from this the contents calculated. 

The composition of the gastric juice in dilated stomachs will depend 
on the disease causing the dilatation. In general there are two groups 
of cases, — one with acid and the other with anacid contents. The 
rormer includes cases of ulcer and of continuous secretion, the latter 
those of cancer and chronic gastritis. As a rule the mucosa of a dilated 
stomach becomes less sensitive to stimuli, owing perhaps to the con- 
stant presence of food and to the gradual development of a chronic 
gastritis, and so secretes less acid. 

Of 45 of our benign casts, 7 were hyperacid, 15 showed normal acidity, 9 
hypoacidity with, and 4 without, any free hydrochloric acid. 

By " hyperacidity" is meant the secretion of abnormally acid gastric 
juice during digestion, that is, while there is normal stimulus for 
secretion. By " hypersecretion" is meant a secretion of gastric juice 
in amount out of proportion to the physiological stimulus, or when 
this is absent. Hyperacidity is qualitative, hypersecretion is quantita- 
tive, yet they usually coexist. Hyperacidity often exists without 
symptoms, is, in fact, often a constitutional anomaly; hypersecretion 
is always pathological and produces pathological results (Riegel). 

Hyperacidity, Superacidity, Hyperchlorhydria, or Hyperaciditas 
Hydrochlorica. — This secretion of very acid juice during digestion, 
but not on the empty stomach, involves not alone the total acidity, but 
especially the increased free hydrochloric acid. There might, indeed, 

18 Zeitsch. f. physiol. Chemie, vol. xxiv. 
"Arch. f. Verdauungskrankheiten, Bd. 2. 



368 



CLINICAL DIAGNOSIS 



be a high total acidity due to a large amount of organic acids which 
would not come under this head. 

This may be due to nervous causes, to defective nervous control, 
or to changes in the mucosa. After the Riegel meal the motility is 
found normal or even increased (hyperkinesis), and the stomach empty 
at the end of six or seven hours, and sometimes even in three to four 
hours, the food being discharged into the intestine before it is ready. 
The acidity per cent, is often 100, sometimes 150 to 160 or more 
following the meal, and over 70, and even 100 or more, with the test 
breakfast. The free acid after the meal is 60 to 80, after the breakfast 
from 50 to 60. Organic acids are absent. Others (Meunier) say the 
acidity alone is not important, but the specific gravity must be low, 
1007 to 1019 instead of 1022 to 1040, as normally. 

The digestion of meat is excellent, but not that of starch. Absorp- 
tion is good. Some of these cases are certainly functional, while others 
are secretory neuroses. For this latter diagnosis all causes for gastric 
disease must be excluded, and the increased acidity should vary with 
the nervous symptoms and be very variable, hence the term " heter- 
ochylia " (Hemmeter), while in chronic gastric disease the acidity is 
quite constant. The hyperacidity may be present only during certain 
periods and following certain nervous stimuli, an important point in 
a diagnosis at best difficult. 

Hypersecretion, Supersecretion, Continuous Secretion " Gastro- 
succorrhcea." — In continuous secretion the secretion continues when 
the stomach contains no food. If the bread of the Ewald breakfast 
be given without the water, and much is removed, it means true hyper- 
secretion due to a disproportion between stimulus and response — the 
free acidity is relatively high, which is a valuable point in ruling out 
motor insufficiency. Continuous secretion is determined by finding 
much acid gastric juice in the fasting stomach and without anything 
to indicate stasis. To exclude food the stomach must be well washed. 
This condition may be constant or intermittent, a part of a general 
neurosis, a secretory neurosis, or the result of organic nervous disease. 
Among the last may be mentioned the gastric crises of tabes dorsalis ; 
among the first are cases of gastroxynsis (Rossbach) . 20 It is seen 
in neurasthenia and hysteria, myelitis, general paralysis, and even the 
excessive use of tobacco. In the periodic or intermittent cases (Reich- 
mann's disease), during the intervals the person's digestion may be 
perfectly normal. Then occur sudden pains, acid eructations, and the 
vomiting of a cloudy yellowish fluid, first with food, then pure, often 
several hundred cubic centimetres of fluid of normal or increased 
acidity, the latter usually only when food is present (total acidity 30 
to 50, abundant free HQ). 

^Deutsch. Arch. f. klin. Med., Bd. 35. 



THE GASTRIC CONTENTS 



3G9 



In the diagnosis of the chronic cases, many of which are considered 
as functional disturbances, all that is necessary is to find considerable 
gastric juice in the food-free and previously empty stomach, and in 
amounts over 100 cc. (Some consider 50 cc. a safe limit; and some- 
times 1000 cc. are found.) Many doubt a "functional" form, and 
believe that there is some pyloric stenosis, due to ulcer or its sequelae, 
always present, that some food is therefore retained, and that the 
motor disturbances resulting are more important than the secretory 
abnormality. 21 These chronic cases are of long duration with a 
gradual onset. There is discomfort, the feeling of weight, acid eructa- 
tions, pain at the height of digestion, which increases until relieved 
by vomiting. Night vomiting is especially characteristic. The pain 
often occurs before the meals and is relieved by eating. From 500 cc. 
to 1000 cc. or more may be vomited in severe cases, of cloudy fluid, 
which on standing separates into three layers. The gastric juice is 
either normal or slightly hyperacid. 

Riegel recommends in the diagnosis of these cases, first, the removal 
of the contents at the height of digestion after a full test meal ; then on 
the following morning the fasting stomach is tested. On the third 
morning the tube is again introduced, the stomach having been washed 
the previous night. One must be careful to lavage the stomach until 
he is sure that it is perfectly clean, for food fragments often remain. 
After the test meal one often gets over one litre of contents, with a 
total acidity per cent, of from 90 to 100, free HC1 50 or more (sp. gr. 
1004 to 1006.5). A case reported by Thayer is a good illustration. 
It was of two years' duration ; the total acidity after the Ewald break- 
fast was 113; the fasting stomach always contained even 420 cc. of 
acid fluid, acidity per cent, often 117; digestion was good. 

In these cases dilatation of the stomach results, and sooner or later 
yeasts and sarcinae may be found. As above said, some think that 
these cases are not true hypersecretion, but that the primary element 
is the atony of the stomach, which allows a certain amount of gastric 
juice to remain, which fluid serves as a stimulus to further secretion. 
Riegel considers that the atony alone is not sufficient, since in so many 
cases of motor insufficiency the stomach will remain empty after 
it is washed out, and not secrete more if some water is left in, hence 
some other factor is necessary to explain the secretion. Again, much 
of the motor insufficiency is the result of the hyperacidity and hyper- 
secretion, which cause spasm of the pylorus, hence failure of the 
stomach to empty itself, and hence dilatation. In several cases of 
dilatation of the stomach relieved by operation the condition soon 
recurred, showing that the secretory abnormality was the basis of 
the trouble (Riegel). It must also be admitted that such stomachs 
21 Kaufmann, Am. Jour. Med. Sci., 1904, vol. cxxvii. 

24 



370 



CLINICAL DIAGNOSIS 



are abnormally sensitive to stimulus, while in simple dilatation with 
stasis the mucosa does not respond with normal irritability, but seems 
dulled by the constant presence of food. 

Other such cases ordinarily called nervous are supposed to be 
reflex disturbances from the intestine and are relieved by treating this' 
organ. 22 

Nervous Dyspepsia. — Hyperacidity, hypersecretion, anacidity, are 
conditions which may accompany a variety of disturbances, and as 
terms they refer only to the chemical composition of the gastric juice. 
These abnormalities of secretion may be due to organic changes of the 
mucosa, to functional disturbances following bad habits of eating, poor 
food, etc., or be a part of a general neurosis, " nervous dyspepsia." 
In this country the last is an exceedingly common manifestation of 
neurasthenia which stomach specialists abroad speak of as the " Amer- 
ican disease." Yet it is exceedingly difficult to separate the element 
due to food, rapid eating, etc., from the neurotic element, and in 
the majority of cases perhaps both coexist. There is usually good 
reason for gastric distress, and a neurasthenic will often worry his sub- 
liminal gastric sensations into the sphere of consciousness. 

Some of these " neurasthenics," if one tests their gastric juice, have 
hyperacidity; more, slight subacidity; and many, normal conditions. 
It is interesting that their subjective symptoms bear so little relation 
to the condition of the gastric juice. A patient with hyperacidity may 
describe sensations quite similar to those of an anacid case, unless there 
is vomiting in the former case, which feature the' latter is, as a rule, 
spared; and one with apparently normal gastric juice sometimes com- 
plains as much as either of the others. 

In this clinic during the past four years we have had 300 such cases. We 
have made no effort to separate " functional" cases from the purely neurotic. 
Eighty-two were cases of hyperacidity (this includes the cases of supersecretion 
and continuous secretion; all figures quoted are those of the Ewald breakfast). 
Of 20 others the clinical features were hyperacidity, although the total acidity was 
not over 70. In 36 cases the total acidity was 70 to 80, the free 33 to 69 (the major- 
ity from 45 to 55) ; in 21, from 80 to 90, free acid 32 to 68 (the majority 55 to 65) ; 
in 15, from 90 to 100, free acid 53 to 85; in 10, from 100 to no, free acid 60 to 
89. As regards amount of fluid obtained one hour after the test breakfast, over 
100 cc. were obtained in the first group (total acidity 70 to 80) in 30 per cent, 
of the cases ; in the second group, in 35 per cent. ; in the third, in 20 per 
cent. ; while in the group with total acidity over 100, in 29 per cent. 

Subacidity (total acidity less than 40) was present in 170 cases, in 61 of 
whom there was no free hydrochloric acid. In these 61 cases the total acidity 
was seldom over 20, in 18 was 10 or less, and in 4 the fluid was practically neu- 
tral to litmus. It is of interest that in these subacid cases in but 4 per cent. 
Was more than 100 cc. obtained, while in 8 per cent, nothing could be siphoned 
off at the end of one hour. In 148 cases the gastric juice was found practically 
normal. This may illustrate the lack of parallelism so often seen between the 
sensations and the chemical findings, but one must also consider the possibility that 

22 Faber, Arch. f. Verdankhtn, Bd. 7. 



THE GASTEIC CONTENTS 



371 



the test breakfasts were not given at the best time to observe the abnormality in 
secretion. 

Acute Gastritis. — By this is meant an acute irritation or inflam- 
mation of the superficial layers of the mucosa, resulting in increased 
mucus secretion, or desquamation of the epithelium, and disturbance 
of secretion. It may be primarily due to the direct irritation of foods, 
poisons, or intoxications, heat, cold, etc., or, secondary to various 
chronic diseases. The vomitus of these cases is acid in reaction, of a 
bad odor, often fermented, the food undigested as a rule and with 
much mucus. The total acidity is diminished, free hydrochloric acid 
absent as a rule, and often organic acid present. Rarely is the reaction 
neutral. If there has been much retching, the vomitus is bile-stained 
or even pure bile. A test meal will show mucus, undigested food, 
and little or no free HQ. 

We have records of but five good cases, all with subacid or neutral fluid. 

Gastritis phlegmonosa or interstitial purulent gastritis 
is a very rare condition. It is an inflammation of the entire gastric 
wall even to the serosa. When localized it gives rise to gastric abscess. 
Vomiting is present, as a rule. In the 60 diffuse cases reported, how- 
ever, pus has not been present (Riegel), but has been in a very few 
cases of abscess. 

In the gastritis acuta purulentia (Leube) the inflammation is 
limited to the mucosa. 

Chronic Gastritis. — Chronic gastritis is not nearly as common as 
is its diagnosis. It exists in all grades to atrophy of the mucosa. 
Functional disturbance must first be excluded, and only those cases 
included in which there are definite signs of gastritis with increased 
mucus formation. One of the commonest symptoms is vomiting, 
especially on an empty stomach in the morning or at the height of 
digestion, of undigested or poorly digested food mixed with mucus. 
If on the fasting stomach, it consists of bile-stained mucus, well seen 
in the morning vomiting of alcoholics. 

The test meal must be tried. The amount removed is about 
normal. The food has the appearance as if just swallowed, and much 
mucus is present which is intimately mixed with the food. This ren- 
ders its removal through the tube difficult and its filtration tedious. The 
presence of this mucus is indispensable for the diagnosis, since large 
amounts from the stomach indicate catarrh. The macroscopic appear- 
ance is the best standard for amount. To judge the amount of mucus, 
however, the stomach must be thoroughly washed, since the most 
appears in the later washings. Hence it is that the vomitus is so often 



372 



CLINICAL DIAGNOSIS 



deceptive in this particular. The needle douche tubes are often 
valuable. 

The secretion is usually diminished, and in late cases with atrophy 
of the mucosa there may be no secretion at all. Free hydrochloric acid 
is diminished or absent, but the total acidity varies and for short 
times the free acid may return, hence the necessity of repeated exam- 
inations. There are cases of acid gastritis, but they are rarely 
diagnosed, though this may be due to the fact that they are an early 
stage before the patient consults a physician. 

Of our 27 cases, one was slightly hyperacid (72, total acidity) ; in 10 the 
acidity was within normal limits, and in 15 below 40, nine of whom had no free 
acid. Four of these could be termed atrophic catarrh, and one additional case, 
from which stomach could be obtained by the tube but 1 cc. or more of bile- 
stained mucus, at autopsy was found to be a case of cirrhosis of the stomach. 

For the diagnosis of a gastritis acida it is necessary to find in the 
fasting stomach mucus with many cell nuclei and a hyperacid juice. 

As a rule, there is diminished secretion, and as the case progresses 
the secretion becomes less and less ; pepsin is also reduced. Organic 
acids are present when there is considerable atony, and then only 
in small amount. Proteid digestion suffers, yet there is usually enough 
gastric juice to digest some. Starch digestion is not disturbed; the 
rennet is diminished as well as the pepsin, and is considered by 
Bouveret as a good criterion for the intensity of the case and for 
prognosis. The amount of fermentation will depend upon the motility. 
Einhorn considers that in chronic gastritis one commonly finds frag- 
ments of the mucosa in the wash-water. Motility is sometimes normal, 
sometimes increased, or sometimes diminished. If normal or in- 
creased, the intestine will act vicariously and hence very few symp- 
toms be present. If decreased, these are more severe, and yet, from 
the presence of undigested food at a time that the stomach should be 
empty, one cannot conclude that motility is disturbed, since normally 
only food which is digested to a certain point is allowed to pass into 
the intestine. Again, in such cases there is often a slight obstruction 
at the pylorus due to the inflammatory swelling of the mucosa. 

Mucus. — Mucus in the stomach washing is present in delicate 
transparent flakes, never in balls, is mixed with the food, and sinks in 
water. These flakes may not be present in the vomitus or in the si- 
phoned fluid, but may be obtained in abundance if the stomach be well 
washed out, especially if a needle douche tube be used ; hence from the 
meal or vomitus alone a wrong opinion concerning the amount of 
mucus is sometimes obtained. The mucus from the respiratory pas- 
sages is in balls, glairy, usually contains air, is therefore frothy and 
swims in the water, often contains epithelial cells and pigment which 
will disclose its origin. It is not mixed with the food. The gastric 



THE G-ASTEIC CONTENTS 



373 



mucus contains the nuclei of leucocytes. When digestion is poor these 
cells may remain well preserved. The presence of mucus in the 
washings may not indicate an increased secretion, since that normally 
secreted may not have been digested because of the lack of hydrochloric 
acid. Mucus is normally increased on a starch diet, e.g., yet so little is 
present that one must hunt for a few flakes even in the centrifugalized 
washings. A great increase of gastric mucus indicates a gastric 
catarrh. Mucus is normally digested by the gastric juice one-half 
as fast as is albumin. Again, when there is a little acid present the 
mucus may swell and hence appear large in volume. It is remarkably 
increased in carcinoma of the stomach and in chronic gastritis with 
atrophy of the mucosa. The reason for its increase is in considerable 
doubt, and is attributed to an abnormal stimulation of the mucous 
cells of the glands, which after all secretion of pepsin and acid has 
ceased will continue to form even more mucus than normal. In 
some cases with hyperacidity there is an increased mucus production, 
but this is not the rule, for in general mucus and hydrochloric acid 
vary inversely. To get an idea of the amount of mucus present the 
acetic acid test cannot be used, since acetic acid does not precipitate 
partially digested mucus. 

Atrophy of the Mucosa. Achylia Gastrica. — Achylia gastrica 
may be due to* a functional disturbance of an apparently normal 
mucosa or to real atrophy of the mucosa ; and the latter, the end stage 
of a. chronic gastritis or the result of cancer and other diseases which 
lead to degenerative changes in the mucosa. When due to atrophy 
it is a gradual process, the secretion diminishing until finally there is 
almost no gastric juice. The diminished secretion may be due to a 
very small cancer, and much of the mucosa seem intact ; it seems due 
to some toxic substance from the tumor. Achylia gastrica can exist 
when there is cancer in other organs (breast, intestine, oesophagus, 
uterus, et al), and before any disturbance of the general health. In 
conditions with general malnutrition achylia may be present. The 
cases of particular interest are those which resemble pernicious anaemia. 
Their gastric trouble may not be suspected provided the motility of the 
stomach be good, yet if slight atony also exist the gastric symptoms 
will be evident enough. If the motility is good the intestine will act 
vicariously. 

Some cases are of nervous nature. Einhorn reports such a case of 
five years' duration of achylia and then a return to normal. The 
discovery may be purely accidental. On the other hand, the nervous 
symptoms may disappear, leaving the achylia still in evidence. 

Atrophic stomachs are very susceptible to injury, and it is not 
uncommon in. the* washings to get pieces of mucosa which seem to 
show a granular gastritis. Such cases vomit often, not always, and, 



374 



CLINICAL DIAGNOSIS 



as a rule, soon after eating, the vomitus consisting of undigested food, 
and is almost never bloody. For diagnosis of achylia the test meal 
is necessary, and this perhaps is the condition in which the test meal 
gives the most positive results. It should be repeated several times. 
It is impossible to remove much. The food is little changed, the 
total acidity is very slight, from i to 4. There is no free HC1. Lactic 
acid is rare unless there be severe ectasis. To diagnose the anatomical 
condition is more difficult. The ferments may fail, an important point 
in diagnosis. It is easy in washing out the stomach to get fragments 
of mucosa and traces of blood showing the vulnerability of the mucosa. 
Mucus is, as a rule, absent, yet early there may be much, and later the 
mucosa may consist chiefly of mucous cells, the glandular cells having 
disappeared. To obtain nothing through the tube does not necessarily 
mean an empty clean stomach, since by washing the dry contents may 
be removed. Eisner, 23 et a/., consider the vicarious action of the intes- 
tine to be overrated ; undigested food should be retained, and if the 
stomach is washed out this will be found. 

Eisner's method of measuring motility is to wash the stomach out well one 
hour after the test meal. This fluid is allowed to stand in a graduated cylinder 
for twenty-four hours, then the amount of residue read after several decantings. 
If there is over 210 cc. of residue there is motor insufficiency in addition to the 
achylia. 

Ulcer of the Stomach. — The clinical types of this disease are : 

( 1 ) The latent form which may pass unsuspected or until hemor- 
rhage or perforation occurs. 

(2) The hemorrhagic form, which may be acute and sometimes 
fatal, or chronic, causing considerable anaemia and cachexia resulting 
from the frequent small hemorrhages, the stools always containing 
a certain amount of blood. 

(3^ The acute perforative. 

(4) The chronic dyspepsia, in which case the dyspeptic symptoms 
are the most evident, and the characteristic symptoms of ulcer vary, 
the most important chemical signs being the hyperacidity and the 
absence of mucus. 

(5) Neurotic, or gastralgic type. 

(6) The vomitive form, with vomiting as the worst symptom. 

(7) The cachectic form, which presents the picture of a cancer. 

The cardinal symptoms of this disease are : (1) Increasing dys- 
pepsia, usually of long duration. (2) Pain, paroxysmal and local, 
from half an hour to two hours after the meal when peristalsis is most 
actively rubbing the food across the ulcer. (3) Vomiting of well- 
digested food and acid vomitus, usually one to three hours after the 
meal at the height of the paroxysm, but often in the morning also 

23 Deutsch. med. Wochenschr., 1904, No. 42. 



THE GASTEIC CONTENT* 



375 



since the juice is hyperacid, and is followed at once by a diminution 
of the pain. (4) Blood is only at times present, and in from 30 to 
50 per cent, of the cases. As a rule, it is dark in color, due to the 
hsematin formed by the hydrochloric acid, although if the stomach be 
empty it may be arterial. There is often blood in the stools intimately 
mixed with the food, but not as constantly as in cancer. In case the 
blood rests a long time in the stomach the vomitus may be of coffee- 
ground appearance, but in that case iron, wine, coffee, medicines 
and food must be excluded. In many cases the blood of the stools 
is unsuspected. Other sources of hemorrhage must be excluded, — 
tuberculosis, cancer, chronic passive congestion, cirrhosis of the liver, 
rupture of an oesophageal varix. (5) Hyperacidity is a classical 
symptom and yet Ewald says it is present in but about half the cases. 
The digestion is good and motility usually rapid. In an average of 
75 cases tested with the Riegel meal he found the total acidity to 
average 105, the average free HC1 50, with a maximum of 89. But 
the acid may be diminished because of other diseases of the mucosa, 
catarrh, etc. These two groups must be distinguished, the fresh and 
the old ulcers, for in the latter the acidity is much lower. 

The result in such cases may be stricture, or severe anaemia due 
to the insufficient nutrition, vomiting, or hemorrhage. In case the 
blood is lost chiefly by the stools the ulcer may be unsuspected and 
the case be diagnosed as pernicious anaemia. Cancers may develop 
on the bed of the ulcer, — in fact, some think the majority of cancers 
begin thus, — and at the time of death the acid still be considerable. In 
most cases it gradually diminishes until the picture is typical. One 
examination of the gastric juice is never enough. Repeated examina- 
tions must be made in order to get a general idea of the acidity. In 
the case of developing cancer it is the variable yet diminishing acidity 
which is important, and yet cases of ulcer may have a normal or 
diminished amount of hydrochloric acid. 

The 82 cases of this clinic have been reported by Howard. 24 Vomiting was 
present in 85.3 per cent., especially in the cases with ulcer at the pylorus. Vomiting 
of blood occurred in 75.6 per cent. ; in one-third only was the blood bright red. 
After the test breakfast more than 50 cc. was obtained from 54 per cent., 27.5 per 
cent, showed hyperacidity, 42.5 per cent, subacidity (for these figures the acidity 
per cent, of 60 was considered the upper limit of normal). In 18 per cent, there 
was no free hydrochloric acid, in 14 per cent, lactic acid. 

Duodenal ulcer is often impossible to diagnose. Yet the posi- 
tion of the pain, its late occurrence after the meal, and the fact that 
all the blood will appear in the stools is suggestive. Hyperacidity may 
be present. These ulcers are more often latent than are the gastric. 

Hemorrhagic Erosions. — It is doubtful whether there is for this 

24 Am. Jour. Med. Sci., December, 1904. 



376 



CLINICAL DIAGNOSIS 



a characteristic complex which as yet can be recognized. The most 
valuable point is that in washing the empty stomach there have been 
found usually fragments of the mucosa without marked pathological 
changes. Vomiting is rare. The acidity is normal or diminished, 
rarely increased. 

Cancer of the Stomach. — Clinically these cases may be separated 
into the latent, those with cachexia but no gastric symptoms, and those 
with localizing symptoms. The important diagnostic points of this 
disease are its rather sudden onset with dyspeptic symptoms in a person 
beyond middle life, unless it be a case that develops on the base of an 
ulcer the symptoms of which have long preceded it ; loss of weight and 
strength ; anaemia ; pain ; vomiting ; and on chemical analysis lack of 
free hydrochloric acid, the presence of lactic acid and of the Oppler- 
Boas bacillus. 

Of these local symptoms and signs, however, any one may be 
absent. Vomiting is common (in 85.3 per cent, of our first 150 cases), 
yet it depends upon the position of the cancer; if at the pylorus 
causing stenosis, the vomiting will be late after a meal ; if at the cardiac 
orifice, there will be regurgitation at once after eating. There is least 
vomiting when the cancer is on the stomach wall. If there is no stenosis 
at either orifice, there will often be none, yet in 6 of 30 cases with 
the cancer at an orifice there was none. In those cases with dilated 
stomach due to stenosis the amount of vomiting is often from a half 
to one litre or more of food, in which may be recognized that eaten 
days before, in one of our cases four weeks (Osier and McCrae). The 
albuminous part of the food is poorly digested, hence the meat in 
lumps, with mucus often, sometimes decomposed and often with 
digested blood. Some hemorrhage is almost constant. It is parenchy- 
matous as a rule, and yet it may be rapid and fatal. It is often an early 
feature, and leads to the diagnosis of ulcer. Often the patient will not 
know of the hemorrhage unless his stomach be washed out or his stools 
be carefully examined, since it is gradual and the blood by digestion 
takes on the so-called " coffee-grounds " appearance and is mixed with 
food. Of the 150 cases reported by Osier and McCrae, vomiting of 
blood occurred but in 21.8 per cent., but careful examination of the 
stools showed it present in almost 100 per cent. 

The gastric features of cancer may be grouped as follows : First, 
those due to the pyloric stenosis, with subsequent dilatation of the 
stomach and stasis of the contents, hence fermentation, decomposi- 
tion, etc. In some other cases the motility is excellent or even in- 
creased, as in 1 1 of 76 cases, in which it was hard to get any fluid at 
the end of an hour. Second, those due to the chronic degenerative 
changes of the mucosa which begin early and develop late; the grad- 
ual diminution in the amount of secretion, e.g. And lastly, those due 



THE GASTRIC CONTENTS 



377 



to the cancer itself. Among these are the early absence of free hydro- 
chloric acid, perhaps the presence of lactic acid, and possibly the 
presence of the long bacilli in chains. 

To consider first the symptoms due to the cancer per se; absence of 
free hydrochloric acid is an early and important sign of cancer, present 
in over 80 per cent, of cases at first examination, yet alone not of great 
importance, not even when other signs are present ; in cases of per- 
nicious anaemia, for instance, there are many features of cancer, and 
in gall-stones with the pylorus in a mass of adhesions, and hence 
palpable tumor, the free HQ may fail. In 163 cases of this clinic the 
free acid was absent in 146, or 89 per cent. 

Again there may be a group of cases without previous symptoms 
of ulcer which begin with hyperacidity (Ziegler). The total acidity 
may not be in the least diminished and total chlorides be high. The 
acidity varies considerably from day to day, and, in fact, even with 
the presence of free acid a variable acidity, with sometimes free hydro- 
chloric acid and another day none, may lead to the diagnosis of 
carcinoma. 

This was well seen in a recent case early in the disease, and was a point 
leading to operation. In fourteen days, of the three Ewald breakfasts given the 
acidities were total 121, 100, 37, and free HC1 11, 16, and 10 respectively. 

The lack of free acid is at first certainly due to the binding of 
this acid by some body which itself does not react alkaline to litmus, 
yet which prevents the hydrochloric acid from giving the Giinzberg 
or other tests for it in its free state. The idea originally suggested 
by v. de Velden, that there was a secretion of the cancer which bound 
the acid, is the idea now again advanced. Later, as a result of the 
changes in the mucosa, brought about perhaps by this secretion of the 
cancer, the total amount of acid will gradually diminish to a very 
small amount; but it is to be emphasized that the conditions causing 
its absence vary early and late. Early with normal total acidity 
absence of the free hydrochloric acid is one of the most important 
signs; later the amount secreted is diminished. In these early cases 
it is very interesting that the disappearance of free acid may be 
sudden, and that following the excision of the cancer the free hydro- 
chloric acid has returned a day or two later; again, in cases of car- 
cinoma of the duodenum or oesophagus the disappearance of free 
hydrochloric acid can be best explained as due to fluid from the 
tumor which flows into the stomach; the cancer may be small and 
very local, but its effect considerable. What these bodies are which 
bind the free hydrochloric acid has been a subject of considerable 
investigation. Certainly hydrochloric acid, if introduced into the 
stomach of a carcinoma case, is soon neutralized (Stahelin). They 



378 



CLINICAL DIAGNOSIS 



might be the products of albuminous digestion, — albumoses and pep- 
tones. The hexone bases would have this same power and have been 
demonstrated in the products of peptic digestion of even half an hour's 
duration ; Reissner ascribed the lack of free acid to the secretion of 
mineral alkalies from the tumor, but this is unsatisfactory, since the 
resulting chlorides would react neutral, and hence reduce the total 
acidity, while in typical cases of early carcinoma of the stomach the 
contents show a total acidity which is not diminished and may be 
higher than normal, yet with no free acid. It is true that evidence is 
given that the dog can secrete sodium carbonate, by this mechanism 
keeping the acid at a physiological level. From work which we have 
done in this connection we believe that the bodies in question are the 
hexone bases, the result of the digestion of the proteid by a ferment 
furnished by the tumor itself. 25 Later the acidity is much reduced, as 
shown by the increasing acid deficit and the decreasing total chlorides, 
and in some cases the fluid may even be alkaline to litmus, as its ash 
usually is. Or, as a result of lavage and general treatment, the acidity 
may be increased so that the case in which free acid was absent may 
later show an abundance. The failure of free hydrochloric acid is 
usually a very early symptom. In cases of cancer developing on the 
base of an ulcer this acidity may be above normal at first. The actual 
disappearance of hydrochloric acid is gradual, but daily variations of 
the free acid occur and are of much diagnostic import. 

Of 64 of our cases without free hydrochloric acid, the juice after the Ewald 
breakfast was almost or quite neutral in 8, below 10 (acidity per cent.) in 20, 
between 10 and 20 in 15, between 20 and 50 in 14, and between 60 and 103 in 
7. The high acidities seemed to depend on the lactic (and butyric) acid present. 

Later the pepsin is diminished and the rennet as well. This is 
due to the chronic gastritis resulting in a diminished secretion of 
gastric juice, and is not specific for the cancer. 

Lactic acid is often an early and very valuable sign in cancer. It 
occurs in about go per cent, of the cases sooner or later, when there 
is no free hydrochloric acid although the bound acid may be abundant. 
It is true that cases of cancer without lactic acid occur, e.g., those on 
the base of an ulcer ; also more rarely lactic acid without cancer, as in 
case of an atonic and anacid stomach, atrophic catarrh with stenosis 
of the pylorus and hence long stagnation of the gastric contents : but 
in the benign cases it is so often absent, even though the stenosis be 
extreme and the fluid anacid. that its early appearance in cancer, even 
before the stenosis is considerable and the total hydrochloric acid much 
diminished, means that these two factors cannot alone explain its 
appearance, and emphasizes the value given it by Boas in the early 



25 Arch. f. klin. Med., vol. lxxii. p. 415. 



THE GrASTEIC CONTENTS 



379 



diagnosis of malignant disease, although the specificity he claimed is 
not granted. 

In 609 of our cases without gastric cancer, lactic acid was present in 30. All 
were cases of subacidity with no free hydrochloric acid. These cases were : 
atrophy of mucosa, 1 ; chronic gastritis, dilated stomach, 4 ; ulcer, 6 ; nervous 
dyspepsia, anacidity, 3 ; pernicious anaemia, 2 ; gall-stones, 1 ; cirrhosis of liver 
with jaundice, 1 ; cancer of gall-bladder, 1 ; pulmonary and peritoneal tubercu- 
losis, 3; and an interesting group of inflammations of the large intestine (ulcera- 
tive colitis, etc.), 5; cancer of ovary, 1; peripheral neuritis and fibrinous peri- 
carditis, 1 each. 

Riegel considers that for its appearance there must be, first a 
diminished secretion involving ferments as well as acid, then stag- 
nation of the contents, and perhaps insufficient absorption. Yet he 
admits that the gastric juice of cases of cancer without much 
atony may contain considerable lactic acid, and that his experience 
of over twenty years shows that the presence of considerable lactic 
acid nearly always means gastric carcinoma. He explains one case 
without stasis by the fissures at the base of the cancer, which allowed 
the retention of acid-producing organisms. Hammerschlag considers 
that it appears only when the ferments are diminished, hence when 
proteid digestion is poor, and is a sign of the diminution in the 
secretion of gastric juice with stagnation and deficient absorption. 
This occurs particularly in carcinoma of the pylorus. 

While the lactic acid may often be determined in a test breakfast, 
this is hardly a fair test since its formation cannot be as rapid as that 
of the secreted acids. It is best therefore to test the contents of the 
fasting stomach in the morning after it has been well washed out the 
evening before and a test meal given (see page 366). 

The cause of the lactic acid may be the organisms in the stomach, 
since several of these have been proven to be acid-producing, among 
them the Boas bacillus; or it may be a normal product of digestion 
evident in these cases because of diminished absorption (an improbable 
explanation to cover many cases) ; or it may be the product of a spe- 
cific ferment furnished by the tumor. This latter cannot be excluded, 
and in the autolytic digestion of proteid by ferments from these tumors 
lactic acid has been shown to arise. 

In our cancer cases the fluid removed one hour after an Ewald bieakfast was 
examined for lactic acid, hence the per cent, which it presents will be minimal. It 
was present in 63 per cent, of 137 cases. The figure given by Scruff was 73.5 
per cent, of a group collected from various writers. 

The gross appearance of the contents is of great importance, since 
the meat is poorly digested and the carbohydrates well. Disturbance 
of motility is due to mechanical obstruction at the pylorus. On the 
other hand motility may be excellent and yet digestion very poor, 



380 



CLINICAL DIAGNOSIS 



which is true in early cancer not situated at the pylorus. Strauss claims 
in such cases we have an abnormal fermentation due to bacteria which 
have remained in the clefts of the tumors. 

Tumor fragments are seldom found. Fragments in blood-clots 
washed from the stomach should be examined. Sahli emphasizes the 
possibility of diagnosis from washing out the stomach well at night 
and the fasting stomach again the next morning; in the latter wash- 
water the fragments of the tumor may be found. Considerable blood 
in various stages of digestion is common. In achylia gastrica frag- 
ments of mucosa may easily be washed loose and resemble cancer. In 
this clinic fragments were found in several cases, but the number de- 
pended on the care with which they are searched for, for in over 70 
cases they were noted but twice, and in a few months after the atten- 
tion of the clerks was called to the need of searching for them several 
cases were found. 

Sarcinse and yeasts are rare. In but five cases of our clinic were 
sarcinae found. The bacteria of the stomach, which are probably a large 



Fig. 64.— Sarcina ventriculi and yeast cells. X 900. 

group, have been divided into the " short" and the " long." The 
former occur in catarrh and ectasis due to benign conditions. The pres- 
ence of many sarcinse is evidence against cancer. That which has 
attracted the most attention is the so-called Oppler-Boas bacillus, which 
occurs in about 80 per cent, of cases (Rutinmeyer), and in almost no 
other condition than here. Cultural characteristics of this organism 
have not as yet been well worked out, and the cultures are so seldom 
made that as the Oppler-Boas bacillus we usually have in mind a group 
of organisms with a few points in common, especially the morphological 
characteristics ; that is, a long, coarse, thread-like bacillus, often in long 
chains which extend across the field of the microscope, in some cases 
present in enormous numbers even filling the whole field. No spores 
are seen. The single bacilli are from 3 to 10, microns long (6 to 8 
microns as a rule) and 1 micron broad, with rounded ends, often 
slightly bottle-shaped ; some are bent. They stain by Gram's, and are 
best seen in stained specimens. Of course, few or many could be 
present, but we never speak of them as Oppler-Boas bacilli unless 



THE GASTEIC CONTENTS 



381 



they are abundant, coarse, and in chains. Some passing under this 
name are surely the Gas bacillus, but the Boas bacillus is not anaerobic, 
and has been found to grow best on media containing blood or its 
derivatives, and hence perhaps its presence so often and so exclusively 
in carcinoma, in which condition above all is present the coffee-ground 
vomitus rich in albumin detritus, the ulcerations and clefts of the 
mucosa, the failure of ferment formation, of acid secretion, and the 
stagnation, which factors Schmidt considers essential. These bacilli 
do not grow well on ordinary media, but will luxuriantly if blood 
be added. They coagulate milk. Kauffmann found the bacillus in 
19 of 20 cancer cases, proved that it was a lactic acid builder, and 
found that it occurred in numbers proportional to the amount of lactic 
acid. Most other lactic acid bacilli are smaller. Other bacilli of 
similar appearance have been cultivated, 26 yet its diagnosis is chiefly 
morphological. Apropos of the number present, a recent case with- 
out extreme stasis may be mentioned, for the gross sediment of the 
stomach washings was almost entirely composed of masses of these 
bacilli. It is not fair to search for them in a recently washed stomach. 
If there certainly is stenosis and these are absent, the evidence is 
against cancer. Kaufmann 27 claims that they cannot grow in the pres- 
ence of free hydrochloric acid of 0.02 per cent., but can well when the 
fluid is acid with phosphates and lactic acid; but others (Rosenheim) 
say they flourish in the stomach in spite of free hydrochloric acid. 

Our series is hardly the right one to furnish statistics concerning the presence 
of these organisms, for only the fluid removed after an Ewald breakfast on a 
cleaned stomach was examined, yet these organisms were found in only 38 per 
cent, of 55 cases in which their presence or absence was noted. In four of these 
cases with the bacilli lactic acid seems not to have been present. 

Heichelheim 28 thinks that in diagnosis clots of blood are very 
important. To find clots containing many of these bacilli, and a fluid 
without free hydrochloric acid, speaks very strongly for cancer ; clots 
with few bacilli strongly suggest it ; clots alone and repeatedly present 
speak in favor of it. 

Pus is sometimes present; in fact, the largest amount of pus that 
we have seen in any gastric case was one of carcinoma. The resorption 
is much disturbed and the KI test almost always delayed. 

Among other tests proposed for the early diagnosis of cancer of 
the stomach is the tryptophan test of Erdmann and Winternitz 29 
which is not constant enough (Sigel in 2 of 15 cases; Glassner in 1 of 

26 See Schmidt, Wien. klin. Wochenschr., January 10, 1901. 

27 Centralbl. f. inn. Med., 1904, No. 4. 
28 Zeitschr. f. klin. Med., 1904, vol. liii. p. 447. 
29 Munch, med. Wochenschr., 1904, p. 299. 



382 



CLINICAL DIAGNOSIS 



2) to be of great value and does occur in other conditions (ulcer, e.g.), 
yet it makes the diagnosis very probable (Orlowsky). 

The presence of over 0.5 p. m. of albumin (Esbach). which Salo- 
mon considered the surest sign, and of urea in the washings of a fast- 
ing stomach without retention, are of some but not absolute value. The 
stomach is carefully washed out ; then in a few hours the tube is again 
introduced and all possible removed, washing several times with 400 
cc. of phvsiological salt solution. The albumin and nitrogen are then 
determined. In all other conditions N = O to 16 mg. per 100 cc, but 
in cancer 10 to 70 mg. per 100 cc. : cancer is probable when N = more 
than 20 mg. and there is a definite albumin precipitate by Esbach's fluid. 
Common ulcer can be differentiated early, although it is the ulcera- 
tion of the cancer nodule which furnishes this inflammatory exudate. 30 

Gluzinski's test for the relative insufficiency of HC1 secretion by 
testing free hydrochloric acid in the morning on the fasting stomach, 
forty-five minutes after the test breakfast, and four hours after a full 
meal, is valuable also to indicate a cancer on the bed of an old ulcer, 
it being positive in 12 of 13 cases. 

Infusoria, and especially flagellates, are sometimes present in the 
anacid carcinomatous stomach at a very early stage. Cohnheim 31 re- 
ported six cases with the Trichomonas and Megastoma entericum, and 
thinks this a valuable sign, even the first, for the early diagnosis of an 
ulcerating cancer of the cardia or lesser curvature ; not in pyloric can- 
cer, since the lactic acid would kill them. They are often present in 
our food and are a temporary inhabitant of the stomach until acid is 
excreted. 

Zabel 32 reported four early cases with similar organisms present in 
abundance. Rosenfeld 33 found them in six cases, one of which he 
thinks is the first non-carcinomatous case in which they have been 
found. He expected this would be true of another case, but a cancer 
was later in evidence. They are found in the small amount of neutral 
or alkaline fluid of these fasting stomachs, together with leptothrix 
threads, long bacilli, and spirilla. It is interesting that they cannot be 
found in other cases of achylia, for we must often swallow them. 

Blood in the gastric contents and stools is a very important, com- 
mon (68 of 70 cases). 34 and early feature, especially in the absence of 
hydrochloric acid and when motility is good. 

Strauss emphasized the disproportion between the relatively active 
fermentation and small amount of sediment in case the cancer is not 
at the pylorus : Reissner. the early increase of chlorides to almost or 

so Berent and Gutmann. Deutsch. med. Wochenschr., 1904, No. 28. 

31 Deutsch. med. Wochenschr.. 1903. 

32 Wien. klin. Wochenschr.. 1904. 

33 Deut. med. Wochenschr.. 1904. 

s *Boas and Kochmann, Arch. f. Verdauungsk, 1902. 



THE GASTEIC CONTEXTS 



383 



quite double, and the alkaline reaction of the ashed gastric contents. 
For Glassner's idea concerning ferments see page 356. 

The early diagnosis of cancer of the stomach is unfortunately a 
late one, if one means by " early " that it is made at a time when the 
patient can be saved by operation. No one feature will help for 
even a fairly early diagnosis. The chemical features may be very 
suggestive, in some cases normal, in some even the reverse of those 
suggesting cancer. The surgeons insist that the diagnosis should be 
made before any tumor is palpable, and this should be the aim of the 
clinical chemist. At present we admit that age and clinical history 
are of far more importance than chemical examination. We would 
never delay operation until the clinical chemist found positive any 
test yet proposed, fearing that when it did become positive it would then 
be too late to operate. 



CHAPTER IV 



THE INTESTINAL CONTENTS AND F^CES 

To determine the motility of the intestine is often important, par- 
ticularly in metabolism experiments to separate the stools belonging 
to the various periods ; also in " latent constipation," one of the " new" 
diseases, in which the food is much too long in its passage through the 
intestine, but the condition overlooked since the stools are normal in 
number and size. It would indeed be fortunate did this condition re- 
move the stigma of neurasthenia from some of our suffering patients. 
The normal motility after a mixed meal is from six to twenty hours ; 
after milk, thirty-six to forty-eight hours. Charcoal or lycopodium 
powder is generally used, one drachm in water after a meal and the 
stools watched until the black charcoal is seen grossly, or the char- 
acteristic lycopodium spores microscopically. Or carmine, 0.5 gm., 
may be given and the red color watched for. Allowance should be 
made for the gastric motility in case the actual time in the intestine is 
desired. Sometimes the charcoal is so mixed in a considerable mass of 
faeces that it passes unnoticed, hence lycopodium or carmine is some- 
what safer. 

Pancreatic Fluid — This when present in the duodenum may be 
obtained, according to Boas, by massaging the contents of the duo- 
denum into the stomach previously washed with 1 per cent, soda 
solution. The patient lies on his back, and the abdomen is massaged 
from right to left from the costal margin to the parasternal line. 
The stomach-tube is then quickly introduced and whatever may have 
been forced back removed. Sometimes about 50 cc. are obtained. To 
prevent the destruction of the ferments' by the hydrochloric acid, soda 
should be added at once. The presence of trypsin is assumed if fibrin 
or egg albumin is digested in alkaline medium. 

Trypsin. Arthus and Huber's Method. — Fresh fibrin is washed 
in water and then heated at 40 0 C. for twenty-four hours with 2 per 
cent. NaF. The solution of fibrin is then filtered. The intestinal fluid 
plus an equal amount of 2 per cent. NaF is mixed with two to three 
volumes of the above-mentioned fibrin solution and kept in the ther- 
mostat at 40 0 C. for some time. If trypsin is present the typical 
crystals of tyrosin will be easily found. Contamination with bacteria 
is not to be feared, for the fluid will remain sterile indefinitely. 

The fat splitting ferment may be demonstrated as follows : 
Neutral olive oil is obtained by shaking out olive oil with ether and a 
little NaOH. The ether extract is shaken out repeatedly with water 

384 



the f^ges 



385 



and the ether then evaporated. An emulsion is then made of oil 10, 
gum 5, and water 35 parts. In several test-tubes (12 mm. diameter) 
are then mixed, litmus solution (neutral and dilute till of a violet color 
against a white background) 10 cc, the emulsion 5 drops, and then 
the fluid to be tested 2, 4, 8, and 16 drops in each respectively. The 
tubes are then put into a water bath (37° C.) at once, and examined 
in a few minutes for the red color. 

To test the diastase the fluid is added to a thin starch solution. 
Soon dilute iodine solution added to a drop of this will give no longer 
a blue color. 

Test-Meals. — All recognize now the necessity of using standard test- 
meals for the examination of intestinal conditions. Strauss recom- 
mends one of chopped beef 100 gms. ; others one of milk. The bowel 
should first be well purged and charcoal, carmine, etc., then given to 
mark the period. 

The standard diet used by Folin,* which must be used by all who 
wish to obtain results comparable with his, and he is the only one who 
has published any complete analyses of the urines of patients on a 
standard diet, is as follows. 



Whole milk, 500 cc. 

Cream (18 to 22 per cent, fat), 300 cc. 

Eggs (white and yolk), 450 gm. 

Horlick's malted milk, 200 gm. 

Sugar, 20 gm. 

Sodium chloride, 6 gm. 

Water enough to make the whole up to 2000 cc. 

Extra drinking water, 900 cc. 



This is the patient's daily diet. It contains about 119 gm. of 
protein, 148 gm. of fat, and 225 gm. of carbohydrate. The nitrogen 
of one day's intake is about 18.9 gm., P 2 0 5 5.9 gm., S0 3 3.8 gm., and 
CI 6.2 gm. 

The Digestive Power of the Pancreatic Juice. — A method which has 
promised much is that of Sahli, who gives with an Ewald test- 
meal 0.15 gm. of iodoform in a glutoid capsule (gelatine hardened in 
formalin). This is supposed to be digested only by the pancreatic 
juice; iodine will appear in the sputum in from a quarter to one and 
a half hours after the solution of the capsule. 

Sahli's results are interesting. Galli 1 condemns this test since in a 
case of carcinoma of the pancreas without any pancreatic juice at all 
the capsule was promptly dissolved. 

Unfortunately, Sahli does not give very explicit directions con- 
cerning the preparation of these capsules, and it would seem that they 

* Am. Jour. Phys, 1905, vol. xiii, p. 64 

1 Deutsch. med. Wochenschr., 1903, No. 19, p. 716, 

25 



386 



CLINICAL DIAGNOSIS 



could be obtained from but one source. This is unfortunate, yet it is 
for those interested in the success of the test a wise provision, since 
so much depends on uniformity in the preparation of the capsules. 2 
For the pancreon test, see page 424. 

In cases of jejunal fistula it is often of importance to know how 
near the pylorus is the opening. A convenient method is to tie a silk 
thread to an oyster. In these cases of practical starvation with the fis- 
tula high up, the motility of the stomach is excessive, as if that organ 
were trying to aid the body by sending the food at once to the intestine. 
In an interesting case in this hospital 3 the oyster appeared at the fis- 
tula's orifice, which, by measuring the length of the string, was found 
to be but one foot below the pylorus. In this same case, after drink- 
ing a glass of milk the milk began to escape from the fistula in one 
minute, and the total amount was recovered in four minutes. 

The examination of the stools is much neglected. It is disagree- 
able but so valuable that it should never be overlooked. As the 
sputum examination is commonly limited to staining for the tuber- 
cle bacillus, so that of the fseces is now a matter of searching for 
parasites when they are suspected, with the result that much that is 
valuable passes undiscovered, and, when examined, the ordinary con- 
stituents, since not familiar, are misinterpreted. 

For this examination are necessary a few tall glass jars in which 
the stools mixed with water are allowed to sediment, some strainers 
(colanders) of various sized mesh in which the stool is ground by a 
pestle, and plates half black half white, the same as used for sputum. 

The constituents of normal stools are the undigested portion of 
food, bacteria, intestinal secretion, formed and unformed elements 
from the mucosa, salts, and products of digestion. The amount varies 
widely with the diet, but a general average is 120 to 250 gms. per 
day. 

The relative amount which bacteria form is enormous. Strass- 
burger 4 estimated them at about one-third the weight of dried stools, 
that is, eight grammes per day, and containing about one-half the nitro- 
gen of the stools. He found more in some dyspepsias, — 14 to 20 gms. ; 
remarkably less in chronic constipation, — 5.5 to 2.6 gms. Strass- 
burger's method was as follows : 2 cc. of the stool is well mixed with 
water and centrifugalized ; the organisms will remain suspended, the 
elements of the food sediment. The fluid is then poured off, consid- 
erable alcohol added to lower the specific gravity, and again centrifu- 
galized. This time the bacteria will sediment. ... This sediment is then 
dried and weighed. Another 2 cc. are evaporated (fresh alcohol 

2 Sahli. Deutsch. Arch. f. klin. Med., 1898, Bd. 61. 

3 dishing. Johns Hopkins Hosp. Bulletin, July, 1899. 
* Zeitschr. f. klin. Med., 1903, Bd. 48, p. 4*3- 



THE F^EOES 



387 



being repeatedly added), dried and weighed. Klein, 5 who uses a 
counting method but who does not even guess the relative volume 
of the bacteria in the stool, takes exception to Strassburger's method 
and results. 

The small amount of faeces during starvation periods consists of 
bacteria, the intestinal epithelium, mucus, and the intestinal secretions. 

Reaction. — The normal reaction is neutral, faintly acid, or faintly 
alkaline, especially the last. If urine be mixed with it, it is of course 
soon alkaline. In a mass of faeces the reaction at the surface may differ 
from that at the centre, and the changes on standing are very rapid. 
In typhoid or cholera they are alkaline, as a rule, in patients on a 
milk or starch diet they may be very acid. 

Frequency. — By diarrhoea is meant frequent and fluid stools; by 
constipation, infrequent movements of the bowels, associated with 
symptoms which are relieved by purging. The normal stool is never 
fluid, but frequency is a variable matter and must be judged from 
the individual stand-point, hence subjective symptoms are necessary. 

Diarrhoea may be due to increased peristalsis, increased intestinal 
secretion, or decreased absorption, and accompanies chronic enteritis, 
chronic peritonitis, intestinal tuberculosis, amyloid disease, cirrhosis 
of the liver, cholera, typhoid, dysentery, infectious diseases, uraemia, 
etc. 

When the trouble is in the small intestine the movements are fluid 
and 1 large but not necessarily very frequent ; in dysentery they are 
frequent and scanty. 

Constipation as a chronic condition is the result of careless habits 
of personal hygiene, of sedentary life, of a diet lacking in the constit- 
uents which stimulate intestinal peristalsis, of dilated stomach, con- 
striction of the bowel, etc. Acute constipation occurs in obstruction of 
the intestine, paralysis of its wall as in peritonitis, and in meningitis 
and other conditions causing increased brain-pressure. In acute ob- 
struction due to intussusception, ileus, etc., the frequent stools of 
bloody mucus but without fecal matter may deceive the doctor who 
does not personally inspect them. 

The consistency and form of the normal stool vary considerably, 
depending on the habit and diet. Pathologically they depend on the 
intestinal secretion, absorption, and especially the motility. The stool 
may be abnormally too fluid or too solid; when very hard it is 
broken up into small masses resembling sheep manure, or somewhat 
larger masses, " scybala," which may be of even stony hardness 
and the size of a walnut. Such stools are common after typhoid fever 
anJ in some cases on a milk diet. These masses may in the rectum 
form large accumulations. When the mass is of very small caliber 
5 Zeitschr. f. klin. Med., 1903, Bd. 48, p. 163. 



388 



CLIXICAL DIAGNOSIS 



it does not necessarily mean a stricture of the lower bowel, since 
such is the form of stool in anal tenesmus, inanition, and certain 
nervous conditions. Boas emphasizes as occurring especially in steno- 
sis of the lower intestine a stool which is homogeneous, thick, pasty 
or curd-like, and in which float short cylinders of formed stool about 
the thickness of the little finger. Such stools must be continuously 
present, however. 

The faeces are abnormally soft : when they contain much fluid, 
which occurs when the motility is so rapid as to exclude absorption, 
when absorption is prevented, or when the intestinal secretion is in- 
creased as in cholera; when there is increased fat; a large amount of 
fruit or vegetable matter, especially cabbage, pear, apple, and plum; 
or, much mucus. A simple way of testing the difference between in- 
creased water and increased fat is to press the cover-glass down over 
a small portion on a slide. If on relieving the pressure the cover- 
glass stays, it is fat, while if it at once springs back and the air 
rushes in from all sides, it is due to water. 

When stools are frothy it indicates an intense bacterial decomposi- 
tion. In such cases they may also appear acholic, due to the changes 
in the pigment. 

Color. — Normally the stools are dark in color, due to hydrobili- 
rubin. The intestine is a reducing organ, hence bilirubin, except in 
a nursing-child, is never normally present. 

The stools are darker the longer they remain in the intestine or 
are exposed to the air. In constipation they may even be tarry in 
appearance. The color also depends upon the food, being dark after 
a meat diet, light after milk ; cocoa gives a reddish-brown color, 
wines a dark color, certain berries a greenish-brown, much chloro- 
phyll a green color. 

The color may depend on drugs ; after doses of calomel they are 
sometimes green, due to biliverdin; after bismuth subnitrate a black 
color, due to bismuth suboxide; senna, santonin, gamboge, and rhu- 
barb give a yellow color. Iron gives a dark brown, grayish, or even 
black color after the stool has stood in the air. This latter point is 
important, since a stool containing blood may resemble that contain- 
ing iron, but the bloody stool is dark when fresh, the latter only after 
standing. 

Clay-Colored Stools. — This may be the appearance of stools 
rich in fat, hence with the color of the bile hidden, but by extracting 
the faeces with alcohol and ether the presence of bile is proved ; of diar- 
rhceal stools which are pale since diluted; most important is the clay 
color due to the absence of bile, the true acholia, which gives the 
stools a grayish-white color with a bad odor, and soft from the 
abundance of fat; of those in which there has been active decompo- 



THE FiECES 



389 



sition with the resulting- formation of the colorless products of bili- 
rubin. In the last case the color is restored by reoxidation in the air 
or after calomel, and the stools are not putrid. This " leucouro- 
bilin" is as yet a rather hypothetical body. Such stools occur in a 
long list of conditions which have nothing in common. 

Bilirubin is found in the intestine not below the lower ileum or 
ascending colon, except perhaps minute traces on masses of vegetable 
or of soaps and found only by such microscopic tests as Schmidt's. 
It is reduced in the large intestine to hydrobilirubin. Some of this 
is reabsorbed, hence more is present in a fluid diarrhceal stool than 
a solid, since it has escaped absorption. Bilirubin occurs in the stools 
of diarrhoea with increased peristalsis, in cases with disturbed ab- 
sorption, or when the reduction is absent. The higher up the point 
of the disturbance the more of this pigment will be found, and yet the 
presence of bilirubin does not always mean trouble in the ileum, since 
some normally does reach the colon, hence may be present in the 
stools in colitis. Such a stool has an intense yellow or greenish color, 
and gives the Gmelin test beautifully. On the addition of one drop 
of yellow nitric acid the green ring of biliverdin can be at once seen. 
A case in which this test was most brilliant was one in Professor 
Miiller's clinic, a case of catarrhal jaundice with clay-colored stools, 
who suddenly evacuated a large, soft, golden-yellow stool. One drop 
of nitric acid produced a most brilliant result. As explanation, it was 
supposed that an obstruction of the gall-ducts had been suddenly re- 
lieved, allowing the escape of a large amount of bile. 

Schmidt's method is valuable to detect bilirubin. In a porcelain 
dish are mixed from 2 to 3 cc. of selected portions of the fresh stool, 
which portions are chosen to represent all the elements present, with 
concentrated aqueous mercuric chloride solution. This is ground 
up fine and allowed to stand twenty-four hours at least in a covered 
dish. Pure mercuric chloride should be used. The whole mixture 
should be acid. The fragments are then examined macroscopically and 
microscopically, those stained with hydrobilirubin turn red, those with 
bilirubin, green. Chlorophyll also will be green, and must be ex- 
cluded microscopically. The biliverdin stage is never passed. Bili- 
rubin occurs in adults only pathologically, and indicates usually an 
enteritis or intestinal catarrh, especially of the small but also the large 
intestine. The bilirubin is found most often on masses of cellulose,, 
next on mucus, then muscle fibres and masses of fat, and lastly on 
the various other constituents. Since in the normal stool traces are: 
not rare on cellulose fragments, it is the occurrence with mucus; 
which is of greatest importance. This mucus may arise either in the 
small or large intestine. If in large glassy macroscopic masses, the 
origin is the colon; if of small macroscopic or of microscopic size. 



390 



CLINICAL DIAGNOSIS 



the source may be the small intestine, especially if the stool be fluid. 
The source is surely the small intestine if the mucus contains many 
nuclei of cells the protoplasm of which is digested, or cells represented 
by fat droplets or bilirubin granules. The question is somewhat differ- 
ent in the case of bile-stained muscle-fibres or connective tissue and fat 
masses, since all in the small intestine are normally stained with bili- 
rubin; hence their presence in the stool may mean trouble only in 
the colon, either too rapid peristalsis, or catarrh; to suggest trouble 
in the small intestine the above-mentioned masses of mucus also should 
be present. 

Schlesinger 6 considers his test for urobilin (hydrobilirubin also) 
very delicate. The stool, if very fatty, is extracted with ether and 
then with acid alcohol. The reaction of the extract is made less acid 
with ammonia, an equal amount of zinc acetate solution ( I per cent, 
in absolute alcohol) added, and filtered. The filtrate gives a good 
fluorescence and spectrum. 

Bile acids are normally reabsorbed, and hence do not appear in 
the stools. 

Fatty Stools. — There is always some fat in the stools, providing 
there is much in the food. This may be as neutral fat, fatty acids, 
or soaps. The more difficultly melting neutral fats are present usu- 
ally as white or yellow scales or droplets, according to their melting- 
point. 

Fatty acids are usually in short, delicate, curved needles, and occur 
in thick masses, so that the shape of the individual crystal is often 
very difficult to make out. The soaps, on the other hand, occur in 
long needles which are arranged in clusters or fans, or in short plump 
crystals, or scales. The droplets of neutral fat are soluble in ether, 
the fatty acids are dissolved on ' warming and in ether, while the 
soaps are not dissolved on warming, nor are they soluble in ether 
unless they have been first split by acid. A test for neutral fat which 
is easily made is to mix the specimen under the microscope with one 
drop of concentrated alcoholic solution of Sudan III. which has been 
filtered just before using. The droplets take an orange to a blood- 
red color, while the soaps and the fatty acid crystals remain un- 
stained. The students attempt to tell from crystal form alone 
whether it is soap or fatty acid crystals they see. A most instructive 
exercise is to give them for study two portions of the same stool, the 
one of which has been extracted with ether (but no acid added), and 
they see at once that the needle crystals are chiefly soaps. 

Acholic stools usually contain much fat in crystals which are 
mixed homogeneously with the fecal matter. Such stools have a 
glistening gray appearance, and microscopically contain large num- 

8 Deutsch. med. Wochenschr., 1903, p. 561. 



THE FiECES 



391 



bers of fat droplets and large masses of fatty acid crystals which are 
very pretty to see. 

In diarrhoea the masses of fat needles are present as minute points 
which may be seen with the naked eye. 

Sometimes the clumps of fat are of a whitish-gray or a yellowish 
color like tallow, even the size of a nut; or the fat may be present as 
a melted oil which hardens over the stool or on the walls of the vessel 
containing it. The whole stool may resemble oil. In a recent case of 
supposed cancer of the pancreas the stool could not by appearance be 
distinguished from a mass of vaseline. 

Such stools occur when there is an over-supply of fat ingested, 
hence especially in the olive oil treatment for gall-stones, in which 
case the lumps may vary from the size of a pea to that of a hazel- 
nut. A much smaller amount of fat may be conspicuous in small 




Fig. 65. — Forms of fats and soaps in stools (Schmidt and Strassburger). <z, soaps; b, casein, 
and fat globules ; c, fatty acid needles and leucocytes ; d, yellow calcium soap ; e, fatty acid crystals pro- 
jecting from fat droplets ; f, fatty acid and soap needles and scales from an acholic stool. 

masses after a meal containing fats with a high melting point, as 
pork, mutton, or tallow. 

Fatty stools are present when the mucosa or the lymphatics can- 
not absorb the fat : as in atrophy of the mucosa ; amyloid disease ; in 
all cases with extensive caseation of the retroperitoneal lymph glands, 
— tabes mesenterica, — the most common cause of fatty stools with- 
out jaundice, and in fact in a doubtful abdominal case the diagnosis 
of this condition is suggested by the stools alone; in peritonitis; 
and even in simple catarrh preventing absorption. There is a fat 
diarrhoea due to various diseases of the small intestine which should 
be distinguished from " diarrhoea pancreatica." 

When bile is absent, from 55 to 78 per cent, of the fat will be in 
stools, instead of as normally from 6 to 10 per cent. Acholic stools 
in cases without jaundice are particularly interesting and may contain 



392 



CLINICAL DIAGNOSIS 



large amounts of fat. The cause of this condition is problematical. 
Some consider that there is a cessation of bile secretion; others that 
in all such cases bile pigment was present but has been changed to the 
colorless forms. 

In pancreatic disease fatty stools are common, yet to be of value 
the stool must be very fatty. Pancreatic disease without them occurs 
since fat is well used if already emulsified, although in such cases the fat 
is insufficiently split. Muller showed that while 84 per cent, of the fat 




Fig. 66. — A sheaf of huge fatty acid crystals seen often in stools after they have stood a little time. X 40°< 

was normally split, if the pancreatic juice be excluded only about 40 
per cent. Others have found more even 80 per cent, split, yet as fatty 
acid not as soap. The diagnosis of pancreatic disease is exceedingly 
difficult, it cannot be made from the fatty stool alone, and yet if all the 
elements of Le Nobel's symptom complex are present it should be 
easy; — no jaundice, glycosuria, much fat in the stools, many fatty 
acid crystals but no soaps, no hydrogen sulphide, skatol, indol, etc., 
the stools rancid but not putrid, and with few bacteria ; if all these 
elements are present one is very safe in assuming some pancreatic 
trouble. 



THE FAECES 



393 



Estimation of Fats and Soaps. — The stool is first evaporated over the water- 
bath until of a semisolid consistency. It is then mixed with about 50 cc. of abso- 
lute alcohol, again evaporated, and this repeated until perfectly dry. Never try 
to dry down a stool without alcohol. A certain amount is powdered, dried at 
ioo° C, and then weighed. It is then rubbed up with sand and extracted from 
eight to ten hours with ether. The ether residue is washed with warm water. 
It consists of neutral fats and the fatty acids. This is dried in a desiccator 
and weighed. 

The neutral fat may be isolated and weighed by dissolving the residue 
again in ether and shaking it out with a dilute soda solution, which removes the 
fatty acids. 

The amount of fatty acids is determined as follows : A weighed amount of 
the ether residue is dissolved in alcohol and ether and then titrated against alcoholic 
solution of potassium hydroxide, phenolphthalein used as indicator. 

For the soaps, the fasces already extracted with ether are boiled with acid 
alcohol, dried, extracted again with ether, and the free fatty acid titrated. If one 
wishes to determine at once neutral fats and the split fats and soap, the stool is 
first boiled with acid alcohol and then extracted (Miiller). 

In fat determinations the following values are used : 

(1) The acid value, that is, the number of milligrammes of potassium hy- 
droxide necessary to neutralize the free fatty acid split from one gramme of fat. 
A weighed amount of fat is dissolved in alcohol and ether and titrated with tenth- 
normal KOH, phenolphthalein used as indicator. 

(2) Kottsdorfer's value, the " saponifying value," that is, the number of 
milligrammes of potassium hydrate necessary to neutralize the fatty acid split 
off from one gramme of fat by saponification. A weighed amount of fat, 1 to 2 
gms., is boiled with 10 cc. of half-normal KOH and 50 cc. of alcohol in a flask 
for a quarter of an hour on the water-bath, and titrated with half-normal acid, 
using phenolphthalein as indicator. 

Heluicr's value is the amount of fatty acid insoluble in water, which can be 
obtained by the saponification of 100 gms. of fat. One saponifies .a weighed 
amount of fat, evaporates the alcohol, and treats the watery solution of the resi- 
due with hydrochloric acid. The free fatty acid is treated with boiling water, 
dried, and weighed. 

The Reichert-Meissl value, that is, the number of cubic centimetres of tenth- 
normal potassium hydrate necessary to neutralize the volatile fatty acids obtained 
by the saponification of 5 gms. of fat. One saponifies a weighed amount of fat, 
acidulated with sulphuric acid, distils the volatile acid, and determines in the 
distillate the amount by titration with tenth-normal KOH ( Thierf elder ) . 

Mucus. — The stools always contain a certain amount of mucus 
(Boas). This is seldom seen even microscopically, and must be 
tested for chemically ; any amount of visible mucus is somewhat ab- 
normal. The mucus present is pure mucin, hence clouded by acetic 
acid. If rubbed up with water, an equal amount of lime water added, 
left to stand for several hours and then acetic acid be added, a cloud 
will indicate mucus. 

Mucus is increased physiologically as the result of hypersecretion. 
This forms a glassy or cloudy coating over hard fecal masses, and 
evidently serves to protect the mucous membrane. It is poor in cells. 
It may also be present after an active purge. 

That from the small intestine is intimately mixed with the stool 
and hard to isolate. In diarrhoea these small flecks can be picked out 
with a needle, and if the stool be solid they can be found as shreds or 



394 



CLINICAL DIAGNOSIS 



lumps which never are bile stained. Such small flakes resemble gas- 
tric mucus. They are rich in cells and detritus of digestion, hence 
are not transparent. The bodies of the cells are often well digested. 
Some masses contain no cells but bilirubin granules and crystals in a 
cellular arrangement, as if the cells had been digested. The so-called 
" sago granules," or " spawn-like masses" of Virchow, Boas thinks are 
very rare. Mucus may be seen microscopically as small transparent 
lines and masses in the stool. The minute mucous granules or 
" islands" of yellowish or greenish mucus stained with bilirubin em- 
phasized by Nothnagel as indicating catarrh of the small intestine 
Boas and Schmidt consider exceedingly rare, and for the most part 
albuminous matter rather than mucus. Yet small fragments are al- 
ways present in acute enteritis. Much mucus is present in cancer of 
the rectum with stenosis. (See also page 420). 

If mucus be present in large amounts the stool may be jelly-like. 
In some cases it consists of mucus alone, is then glassy, jelly-like, 
thick, glistening in appearance, and means trouble no higher than the 
sigmoid. The white strips or tubes even several inches long, some- 
times forming a cast of the bowel, seen in enteritis membranacea or 
colica mucosa, a secretory neurosis, are particularly interesting, indi- 
cating neurasthenia except in rare cases of pelvic tumor pressing 
upon the rectum. Membranous colic occurs mostly in women (80 to 
90 per cent.), and in nearly all cases it is preceded by years of con- 
stipation. Some separate the cases into those with an inflammatory 
basis (enteritis membranacea), and those without, "colica mucosa," 
a pure secretory neurosis; others make no such division. Some pa- 
tients have but one attack, some have one attack a day for even a 
week, and are then free for intervals of months. The masses of 
mucus are transparent, grayish-white or bloody, and are sometimes 
over a foot long. The movement consists of pure mucus without 
fecal matter. These strips of mucus are considered as tapeworms by 
the laity, or when large as pieces of bowel. Some persons will evac- 
uate these at rather regular intervals. Their separation from the mu- 
cosa is often accompanied by very severe colicky pains. Their relation 
to intestinal sand is interesting, since in some cases these coexist and 
both may be due to a secretory neurosis (see page 401). 

In searching the stool for small masses of mucus, vegetable masses, 
and especially fruit, must be excluded. 

Blood. — It is of course necesary to exclude that from raw meat, 
' and hemorrhage from the mouth, nose, lungs, and vagina. The blood 
may be suspected from the red or tarry black color of the stool, 
or found microscopically, or require chemical tests. The arrangement 
is important: fresh blood covering a formed stool indicates hemor- 
rhoids ; if evenly distributed with the food matter, it indicates hemor- 



THE M1@ES 



395 



rhage in the stomach or the upper part of the small intestine, pro- 
viding the stool is solid; if the stool be fluid it may be evenly 
distributed and indicate the small intestine, but usually the colon. In 
a liquid stool the color of the blood is a better criterion than is its 
arrangement, since the darkness in color increases in proportion to 
the height of its source. Tarry blood is seldom of low origin, while 
fluid blood usually comes from the colon or the rectum, and yet may 
be from much higher, in the small intestine as in typhoid fever, pro- 
viding it be quickly enough expelled. In profuse gastric hemorrhage 
the stools may be of a black tarry color. In profuse typhoid hemor- 
rhages, even when from some distance in the ileum, they may be 
bright red. From tuberculous ulcers there may be no blood. In cancer 
of the colon blood has been found in but 15 to 20 per cent. (?) of 
the cases. The bloody serous stools unmixed with fecal matter of 
volvulus and intussusception are particularly important. If the blood 
is fresh there is no difficulty in its recognition, but when there is 
doubt it is usually a hard question. The microscopical search for 
red blood-cells is unsatisfactory, since often no perfect cells are found, 
and all have broken down into masses of pigment, " haematoidin." 
The chemical tests are more satisfactory. Teichmann's acid-haemin 
test does not always succeed, even in a sure case, since the right 
fragment may not have been selected. 

The spectroscopic test is valuable to detect the haemoglobin or 
haematin. Several cubic centimetres of the stool are mixed with 
water and a few drops of sulphuric acid until it reacts well to Congo 
red. It is then filtered and extracted with ether plus a few drops of 
alcohol. The ether solution is brownish-red from the acid haematin. 
In all cases the haematin from the meat must be excluded. 

For the turpentine-guaiac test the stool is rubbed up with water 
and one-third volume of glacial acetic acid, and shaken out with 
ether. A few cubic centimetres of the extract are cleared by adding 
a little alcohol, then treated with ten drops of guaiac tincture plus 
thirty drops of turpentine. The blue color will indicate blood pig- 
ment. This test may be positive, however, if the patient has been 
eating potatoes and certain vegetables, or taking iron as medicine, or 
if there be much bile, saliva, milk or pus present. It is not reliable 
if but little blood is present, and when urobilin disturbs the reaction. 
(See page 396.) 

The aloin test of Klinge and Shaer is more delicate, being posi- 
tive after the ingestion of only 3 gms. of blood, hence more delicate 
even than the spectroscope ; Joachim 7 advises to use both the guaiac 
and the aloin tests. Preliminary to this test Koziczowsky 8 advises 

7 Berl. klin. Wochenschr., 1904, xli. p. 466. 

8 Deutsch. med. Wochenschr., 1904, No. 33. 



396 



CLINICAL DIAGNOSIS 



that all foods containing haemoglobin and chlorophyll and all drugs 
be discontinued. The patient is put on a milk, bread, eggs, and 
fruit diet. Much fat is avoided and the diet period limited by char- 
coal, not carmine. 

The stool if very dark in color is rubbed up with ten volumes of 
alcohol, and this filtered off to remove the urobilin. The stool is 
dried on the filter paper. About 5 gins, is digested one or two 
minutes with 5 cc. of glacial acetic acid, then all fat extracted with 
10 cc. of ether. From 1 to 1.5 cc. of oxygenated turpentine are 
then superimposed and 0.5 cc. of fresh 3 per cent, aloin solution (0.3 
gm. aloin powdered is dissolved in 10 cc. of 60 to 70 per cent, alco- 
hol). At the line of separation is seen in from three to five minutes 
a fine red ring. This means the presence of blood if the patient has 
been on the above-mentioned diet for some days and if the test is 
positive on several examinations. 

All fat must be removed; carmine will disturb the test, not so 
chlorophyll or urobilin; rare meats must be excluded, and all haemo- 
globin-containing foods ; all drugs containing iron. Of course, blood 
from the lung, mouth, and anal region must also be excluded. 

The use of these tests on a large number of cases as a routine has 
developed some interesting results. In cancer of the stomach blood is 
practically always present in small amount in the stools; in ulcer 
of the stomach the blood is often present in larger amounts than in 
cancer, but not every day, there being blood-free intervals. In tuber- 
culosis of the intestine there is none, in typhoid fever the test may 
be positive one day before the hemorrhage; in chronic passive con- 
gestion blood is usually present; also in mercury poisoning. In 
cirrhosis of the liver with venous stasis no blood was found. In 
some cases of hyperacidity of the stomach blood is present. 

The test has the greatest value in the diagnosis of gastric cancer 
and the differential diagnosis of ulcer and nervous gastralgia. 

Pus. — The presence of very much pure pus in the stools indi- 
cates the rupture of an abscess into the intestinal tract ; in some cases 
it may be seen with the naked eye. The extent to which it is mixed 
with the fecal matter will indicate the height of its origin, and yet 
it is soon rendered unrecognizable by digestion and decomposition, 
so that even a large amount will not be suspected, as occurs in cases 
of appendix-abscess perforating into the intestine. The nuclei will 
remain visible for some time, but these cannot be distinguished from 
the cells of food. A small amount of pus, seen only microscopically, 
is often associated with mucus and blood. With blood it indicates 
intestinal disease, as catarrh or ulceration of the intestine, and in many 
cases cancer. Should the pus-cells be for the most part single, 
it is more in favor of catarrh, while if in small masses of even a 



THE FJSCES 



397 



few, it indicates ulcer. It is not to be forgotten that from the normal 
mucosa leucocytes wander out and hence a few pus-cells may be ex- 
pected. Casein curds and masses of albumin must be excluded. 

Muscle and Albumin. — Muscle-fibres occur practically always in 
the stools. The more they are digested the less evident is their stria- 
tion, so that while some will show beautiful cross striation, in others 
only the longitudinal striation is seen, and others can be recognized 
as muscle-fibres only from their shape, size, and color. They are 
nearly all bile-stained. They are increased on a rich meat diet, as 
in diabetes, in diarrhoea, in which case the masses may be visible to 
the naked eye, and where there is disturbed absorption or secretion. 
The question whether there is a pathological increase in a solid stool 
is best judged from their number and appearance (size, shape, stria- 
tion) microscopically. One is soon able to form a pretty definite 
opinion. 

This condition of lientery (the presence of grossly visible parti- 
cles of undigested food) is, of course, seen best in cases with a 
gastro-intestinal anastomosis. It occurs in a variety of conditions. 

The presence of an abnormal amount of muscle-fibre in a fairly 
thick or solid stool and without diarrhoea is known as azotorrhcea, 
which is suggestive but in no way conclusive in the diagnosis of 
pancreatic disease, unless diabetes also is present. 

Curds of milk and masses of coagulated albumin — e.g., coagu- 
lated egg — are seen as masses of amorphous granules forming yel- 
low islands. The masses of milk curd are especially important in the 
infant stool. Soluble albumin, albumose, or peptone may be deter- 
mined in the water extract by the ordinary tests. Normally they are 
present, but are increased in diarrhoea. If the biuret test be used, 
urobilin must be excluded. 

Starch. — It is seldom that single well-preserved starch granules 
are seen in the stool of an adult, yet vegetable masses full of starch 
granules are common enough. If many well-preserved single starch 
granules occur it indicates some disturbance, either diarrhoea or hyper- 
acidity. It is interesting that starch is never bile-stained. In the 
failure of pancreatic juice the starch is not increased, since the bac- 
teria will break it up. Also the lack of bile causes no increase in the 
starch of the stool. The iodine test may be applied to indicate the 
extent to which the starch has been digested, a blue color indicating 
the unchanged granules ; red, a slight digestion. 

Carbohydrates. — To detect these Strassburger recommends the 
following: From 2 to 3 gms. of the dried stool (excluding mucus 
and lactose) are heated in a flask with too cc. of 2 per cent. HC1 for 
an hour and a half (with a return cooler). It is then cooled and 
neutralized quite accurately with sodium hydroxide, filtered through 



398 



CLINICAL DIAGNOSIS 



an asbestos filter, washed with water, and the filtrate brought to 
200 cc. If necessary, it is filtered a second time. Fifty cc. of the 
filtrate are poured into a 300 cc. beaker and the sugar determined 
quantitatively. The amount determined of the grape-sugar multi- 
plied by 0.94 equals the amount of starch originally present. Quali- 
tatively, the stool may be boiled with water and the filtrate then 
tested with Trommer's or other solutions. It is best to precipitate 
the albumin with the acetate of lead : the lead is then removed with 
C0 2 and the filtrate tested. It is seldom, however, that any glucose 
is found unless the stool be first boiled with acid. 

Ferments. — The stool may be extracted with glycerin and the digestive 
power of the extract tested: or, according to Leo, fibrin added, which will absorb 
the pepsin. The faeces are mixed with chloroform water until they form a thin 
pasty mass. In this is suspended from 2 to 5 gms. of finely divided, previously 
boiled blood fibrin enclosed in a gauze bag. In twenty-four hours this bag is 
removed, the fibrin washed a number of times with water, and then tested for 
the ferments which have been absorbed. To test for trypsin, a little of the 
fibrin is placed in a 1 per cent, solution of soda in an incubator and the biuret test 
applied to the nitrate at the end of a few hours. For diastase a little of the fibrin 
is placed in a thick starch solution in the thermostat, and in a few hours its 
filtrate tested with dilute Lugol's for the blue color of starch. Normally, these 
ferments seem destroyed or absorbed in the intestine, yet all may be present in 
diarrhoea. 

Microscopy. — For the microscopical examination of the stools 
care must be taken in the selection of fragments, since the one who 
searches at random will often find nothing. In the case of parasite 
eggs, etc., it is best to mix the stool with water and allow it to sedi- 
ment, or to centrifugalize it. Mucous particles are to be chosen if 
protozoans are the object of search. In searching for blood it often 
makes considerable difference whether the right particle is taken 
or not. 

Epithelial Cells. — Squamous epithelial cells are often found in 
mucus which covers the stool, and come from the anal region; many 
are present in cases of rectal cancer and of proctitis. 

Cylindrical epithelium is the commonest form found. For this the 
mucus should be studied, and especially that which is obtained by 
lavage of the rectum and sigmoid. These cells will show all grades 
of degeneration, from fairly well-preserved cells, even goblet-cells, 
to those which are very fatty, and finally those in which all trace of 
the nucleus is lost. They occur especially in diarrhoea, sometimes 
in such numbers that the term '* desquamative catarrh" is applicable. 

Triple phosphate crystals are almost always present, and are irreg- 
ularly formed, as a rule. Calcium phosphate crystals occur in the 
same form as in the urine. In addition, are calcium salts of still 
unknown acids, which are present in irregular, oval, or circular 



THE FvECES 



399 



masses, sometimes fissured, sometimes with a concentric striation. 
These are always bile-stained. The calcium soaps and calcium ox- 
alate are frequently found (see Fig. 65). 

Cholesterin occurs often, but rarely in typical crystal form, and 
must be tested for chemically. Charcot-Leyden crystals have been 
found in a great variety of diseases, but it is the consensus of opinion 
now that their presence always indicates some animal parasite, al- 
though it may be any, from the harmless oxyuris to the pernicious 
uncinaria. They are, indeed, a very valuable indication when they 
occur in large numbers (see Fig. 67). 

Bismuthous oxide occurs as black irregular rhombic crystals after 
the use of bismuth subnitrate (see Fig. 69). Hsematoidin crystals 
occur, but are rare. 

Remnants of undigested food form the chief part of the picture, 
especially the thorn-like spines from various fruits and berries; the 



spiral cells, of which the veins of leaves are largely formed ; the thick 
cellulose shell of various cells, some resembling soap masses, some 
parasite eggs; the elastic tissue from meats. The list is too long 
and varied to allow enumeration (see Figs. 69, 70). 

Macroscopic Examination. Gall-Stones. — It is often a matter 
of great importance to find these in cases of abdominal pain, and the 
stools should be carefully searched for at least fourteen days after a 
suspicious colic, since the most typical attack may be due to infection 
of gall-ducts without the presence of a stone. The stools are mixed 
well with water and then rubbed through a sieve. The gall-stones 
may not appear in the stool, since the softer ones certainly fall to 
pieces in the intestine, Naunyn thinking that only those with a hard 
rind reach the rectum. Also the stone may have been stopped in the 
duct without obstructing it. Their size may be even as great as a 
pigeon's egg. These stones consist of the calcium salt of bilirubin 




Fig. 67.— Charcot-Leyden crystals from the stools. X 400. 



400 



CLINICAL DIAGNOSIS 



and cholesterin, one or both. They may contain also biliverdin, bili- 
humin, bilicyanin, etc., and calcium carbonate in small amounts. 
Their consistency may be soft or very hard ; they may show on 
fracture concentric layers. Some are smooth, facetted, others rough. 
If facettes are present, it means that more than one stone was pres- 
ent and that the source was probably the gall-bladder. 

Pseudo gall-stones it is of great importance to recognize and to ex- 
clude. These may be woody plant masses, as the hard husks about the 
seeds of the pear. Such can be recognized on cross-section : they are 
harder than gall-stones. Fats, oils, and soaps of high melting point 
also form masses which may deceive. It is for this reason that the 
olive-oil treatment for gall-stones was formerly so popular, for it 
was followed by the passage of large numbers of pseudo-stones, soft, 



// 



Fig. 70.— Spines forming the " down.'* that on the right of a raspberry, on the left of a quince. These 
are often taken for the embryos of parasites. 

fatty translucent masses very different on cross-section from the true 
stones. 

Gall-sand — that is. very small stones (the size of sand grains), which 
sometimes appear in great numbers — may come from the gall-bladder, 
but this is rather doubtful, they probably being pseudo-concretions. 
True gall-sand would be dissolved in the intestine, nor would such 
an amount appear at one time ( Xaunyn). 

The gall-stone is usually recognized from its fractured surface. 
This is necessary, since various intestinal concretions and contents 
(e.g., a bird's vertebra) may closely resemble one. If necessary, it 
may be dried, powdered ( an unpowdered stone will not dissolve since 
it is surrounded by a layer of mucus), and dissolved in alcohol 
and ether, which dissolves the cholesterin. which then will recrys- 
tallize out on evaporation : or the stone may be dissolved in boiling 




Fig. 69.— Cells in stools. A, B, muscle fibers ; C, D, vegetable cells ; E, F, spinal fibers from a piece of 
lettuce ; G, cellulose framework of vegetable tissue. The crystals are of bismuthous oxide. X 400. 



THE FAECES 



401 



alcohol, in which case the cholesterin will precipitate at once on cool- 
ing. If to the residue after extraction of the cholesterin is added 
very dilute potassium hydroxide and cooled, a yellow solution of 
calcium salt of bilirubin will be obtained which will give Gmelin's 
test. If bilihumin be present it will give a blue. 

Pancreatic stones are much rarer than gall-stones. They are 
white in color, and consist chiefly of calcium carbonate, hence will 
effervesce on the addition of hydrochloric acid. 

Enteroliths. — By these are meant incrustations of food masses 
with inorganic salts. Their greatest importance is, of course, in ap- 
pendicitis. They seldom occur in the faeces. The salt present is for 
the most part triple phosphate. 

Intestinal Sand. — Intestinal sand is a very interesting find. By 
this is meant small granules of inorganic salts, the phosphates and 
carbonates of calcium especially, but also of magnesium, iron, and 
other metals. There is also a certain amount of organic matter, also 
fat, a good many bacteria, no cholesterin, sometimes urobilin. They 
are spherical or irregular, very hard, about the size of the head of a 
pin, 0.15 to 2.5 mm. in diameter, often of a reddish-brown or green 
color, and may be found in the stools at certain times in large num- 
bers, even half an ounce at once. Most of the cases thus described are 
of pseudo-sand. Some granules seem of blood pigment, some of 
bile pigment, others of drugs taken (e.g., salol). Some have as 
nucleus a grain of quartz sand swallowed and coated with phos- 
phates; others are the seeds of various berries, or the small hard 
granules from the seed-case of some pear. These can be easily ex- 
cluded by microscopic examination of the cross-section. True in- 
testinal sand, of which we have seen but one good case, seems to be 
the result of a secretory neurosis of the intestine. It occurs in neuras- 
thenic persons, and often in association with membranous colitis. 
Such stools are often preceded by about an hour of severe pain. 
Eichorst refers to it as a u gravel-forming enteritis," perhaps caused 
by bacteria. The large number of bacteria and the reduced bile 
pigment in some indicate the large bowel as the place of formation, 
although the absence of the latter makes Thompson and Ferguson 
think it in their case formed in the ileum. The granules also may, 
as in our case, appear in large amounts at certain intervals not related 
to diet, with nervous symptoms, and without mucus. Calcium sul- 
phate has been found to be the chief constituent of some. 9 

Bedford 10 thinks his case shows a relationship to gout and tophus formation. 

9 See also Garrod, Lancet, March 8, 1902, and Eichorst, Deut. Arch. f. kl. Med., 
1900, Bd. 68, page 1. 

10 Lancet, July 26, 1902. 

26 



402 



CLINICAL DIAGNOSIS 



Tumor Fragments. — Tumor fragments and adenomatous polyps, 
which may occur as an independent disease or grow in the neighbor- 
hood of cancers or ulcers, may appear, having their origin in the 
rectum, colon, or even higher. They are hard to recognize. If the 
stool is thin, these firm fragments of a grayish-red color and firm 
consistency may be found and the diagnosis made from the arrange- 
ment of the nuclei in the sections; but the fine details will all have 
been lost. 

Intestinal Parasites. Protozoa. Rhizopoda. 

Amceba Coli. — This amceba (see Figs. 71, 72) is now generally 
granted to be the cause of the so-called amoebic dysentery ; the bacillary 
dysentery is a different disease. In a well-marked case of amoebic dys- 
entery the stools contain much blood-stained mucus containing large 
numbers of these parasites. It is of the utmost importance that 
the stool be examined while fresh and warm, since the parasite is 



1 



Fig. 71. — Amoeba coli (Entamoeba dysenteriae), common form. X 400. 

very susceptible to cold and to an acid reaction of the medium, hence 
soon becomes unrecognizable. 

Although dysentery is usually present, it is not always, and 
the amoebae may be found in the hard constipated faeces of cases ad- 
mitted during remissions of the disease, for liver abscesses, e.g. It is 
much better to examine the mucus removed by a rectal tube than 
the stool, and a small fleck in the eye of the tube is enough. In any 
case mucus, especially blood-stained, should be searched for, and if 
none found the liquid part of the stool should be examined. It is 
desirable to use a warm stage, although we find the top of the steam 
radiators very satisfactory. Since many degenerated epithelial cells 
and cells from the food look very much like amoebae, the rule should 
be inviolable to always see definite amoeboid motion, that is, the ex- 
trusion of true pseudopods not merely a change of shape, before pro- 
nouncing the object an amoeba. This rule is hard to follow, especially 



Fig. 72. — Amoeba coli ( Entamoeba dysenteriae). An uncommon, very hyaline, and very amoeboid form 
of parasites, usually filled with red blood-cells. The small forms are true amoebae from a normal case, 
Entamoeba coli, drawn to the same scale. X 400. 




a 



Fig. 72a. — Trichina spiralis, a, adult female, b, adult male. X 90. c, embryo. X 400. (I am in- 
debted to Dr. C. L. Overlander, of Boston, for these photographs). 



THE FiECES 



403 



if amoeba-like bodies full of red blood-cells are found in blood-stained 
mucus. 

Biologists may be able to recognize amoebae under all circumstances ; not so 
the clinician. In the intestines occur so many cells which resemble resting amoebae, 
and degenerating cells may show such lively change of shape especially on the 
warm stage, that it is much safer to examine the fresh warm stool, and in case 
no amoebae concerning which there is no doubt, with distinct extension of a hyaline 
ectoplasm from a granular endoplasm, and definite wavy motion of this pseudopod, 
then its retraction, or better a definite progression by means of it, be seen, it is much 
safer for the patient if one looks further for the diagnosis. Of course, the reply may 
be made that these " degenerating epithelium cells" may in truth be the harmless 
form of amoebae, but as these and dead cells are said to have equal pathogenic im- 
portance, the mistake does little harm. 

Amoeba coli is from 8 to 50 microns in diameter. It consists of 
an endosarc which is more or less finely granular and which may 
contain leucocytes, red blood-cells, bacteria, epithelial cells, and parti- 
cles of food which the parasite has ingested, and a clear hyaline 
ectosarc best seen in the pseudopods. These pseudopod s may be pro- 
jected and revolve around the parasite without causing any change 
in position, or by means of them the parasite may move, even so fast 
on a well-warmed stage that it is difficult to follow it ; or the parasite 
may not move, but change its shape repeatedly by projecting one, 
two, or even more pseudopods in various directions. The nucleus is 
best seen in the parasite just dead or which has been killed by acetic 
acid or corrosive sublimate. It is spherical and about 6 microns in 
diameter. As a rule, it is not clearly seen in the living parasite, and 
yet our cases differ in this particular. In some nearly every amoeba 
will have a very distinct nucleus, whereas in others hardly one can 
be well made out, the endosarc of the parasites being filled with detri- 
tus. In the endosarc may also be seen one or several vacuoles which 
do not pulsate. In fact, the parasites in different cases may vary so 
markedly in appearance, in size, etc., that one is always tempted to 
classify them in several groups on this basis. 

Resting forms occur in which, it is stated, the nucleus divides 
repeatedly, and this is supposed to be the form which infects another 
host. 

Since amoebae are found in conditions without ulceration of the 
intestine, in diarrhoea, typhoid, acute and chronic enteritis, colitis and 
proctitis, and in the stools of normal men, some doubt the patho- 
genicity of the parasite, while many separate the pathogenic Amoeba 
coli from a harmless form. Quincke and Ross separated : 

Amoeba coli (Losch), 15 to 25 microns in diameter; encysted * 
forms, 10 to 15 microns, pathogenic to man and to cats. 

Amoeba coli mitis, 25 to 35 microns in diameter, slightly patho- 



404 



CLINICAL DIAGNOSIS 



genie to man causing a mild enteritis, and not at all to cats. This 
form never contains red blood-cells, but many bacteria and other food 
elements. 

Amoeba intestini vulgaris, similar to the " mitis" but not at all 
pathogenic. 

True, sometimes are seen small amoebae, less than half the size of 
the ordinary Amoeba coli, in cases of diarrhoea, with large numbers of 
flagellates. In several recent cases these small active amoebae were 
present in large numbers. They contained no red blood-cells, the 
stools contained neither mucus nor blood. Large numbers of Lamblia, 
Cercomonas, and Trichomonas were also present. 

The best recent contribution to the subject is by Schaudinn, 11 who separates 
Entamoeba coli from Entamoeba histolytica, 12 the former the common harmless 
variety, the latter the pathogenic form causing dysentery. 

Entamoeba coli can be found in the stools of 65 per cent, of normal per- 
sons after a dose of Epsom salt (Craig). Its size averages somewhat smaller (10 
to 20 microns in diameter), it is less actively motile, there is less difference be- 
tween endosarc and ectosarc, the latter is less refractile, the former has less demon- 
strable structure, vacuoles are less common, and the nucleus more distinct than 
in the pathogenic variety. What is more important, the pathogenic variety shows 
no encysted stage, but does multiply by sporulation. (For more details, see Craig, 
loc. cit.) 

Flagellata. — In human parasitology the flagellata which are im- 
portant are of the enflagellata, and of these the protomonadina and 
the polymastigina. Flagellated rhizopods and lower plants must be 
excluded as extraneous. 

Polymastigina. — These are flagellata with three equal or from 
four to eight unequal fiagella inserted at different points. They 
may also have an undulating membrane, often mistaken for a row 
of cilia. Of these are two groups of importance, the Trichomonas 
and Lamblia. 

Trichomonas. — This is a pear-shaped organism, rounded in 
front, pointed behind, with at its anterior end three to four equally 
long fiagella which often are united at their base. The undulating 
membrane, which is usually present but not always seen, begins at 
the anterior pole and extends obliquely backward. The nucleus is 
anterior, and behind it are one or more vacuoles which do not pulsate. 
It is interesting to study the various sizes and shapes of these flagel- 
lated organisms, and their movements, particularly so Avhen in an 
old specimen the fiagella have been withdrawn and then evidently 
the attempt made to extrude them, in which case the membrane is 

11 Arbeit, a. d. K. Gesundsheitsamte, 1903, xix. p. 563. 

12 Craig, Am. Med., May 27, June 3, 1905, considers the name Entamoeba dys- 
enterise better. 




Fig. 73. — Parasite eggs in stools, a, b, c, eggs of trichocephalus dispar, showing the different colors 
(species?) ; d, e, ascaris lumbricoides: d, envelope lost; e, perfect. X 400. 



a b 
Fig. 73a.— Eggs of Tyroglyphus siro (cheese- or flour-mite) . a, an egg magnified X 400 to allow a 
comparison of size with the eggs of Fig. 73. b, in the centre an egg and above and below two mites soon 
after they hatched and had developed somewhat. 100. Note.— We picture these eggs merely as a 
warning to the student that not all the eggs he may find in the stools are eggs of important parasites. 
One not infrequently finds eggs of the great varieiy of harmless insects, etc , which are swallowed with 
the food. When in doubt concerning an egg it should be carefully measured and then the attempt made 
to hatch it. If still in doubt the specimen should be sent to the Washington Laboratories (Department 
of Health). 



THE F.ECES 



405 



projected to some distance in three or four different directions re- 
sembling the struggles of a cat which is tied in a bag. 

Trichomonas Vaginalis (Donne). — This parasite (Fig. 74) is 
from 15 to 25 microns long, from 7 to 12 broad, with its posterior 
end drawn to a thread, its cuticle thin, protoplasm free from granules. 
It has three rlagella, as a rule, which sometimes seem united at base, 
the fourth, which is sometimes described, probably being the edge of 
the undulating membrane. These are of equal length. The undu- 
lating membrane extends spirally backward from the anterior pole. 
This parasite is found in abundance in the acid secretion of catarrhal 
vaginitis. 

In the intestine various forms have been described under such 
names as Protoryxomyces coprinarius, Monocercomonas hominis 
(Grassi), Cimaenomonas hominis (Grassi), Trichomonas hominis 
(Grassi), Cercomonas coli hominis (May), but all of these are now 



considered to be the same as the above-mentioned Trichomonas vag- 
inalis, which parasite can live in the vagina, the urethra, the large and 
the small intestine, the stomach, even appear in the mouth, and be 
found in the sputum from lung cavities and in the Dietrich's plugs. It 
has long been a question whether these parasites were harmless or 
not; whether they caused a diarrhoea or merely aggravated a trouble 
that w T as already present. It is now considered pathogenic, and we 
could mention one or two cases in this connection in which this 
parasite seems to have been the cause of a severe diarrhoea. 

Lamblia (Fig. 75). — This is a family of pear-shaped organisms 
with a deep concavity on their inferior surface and with four pairs of 
nagella, three on the edges of the concavity and one at its posterior- 
extremity. Various names of this parasite are Lamblia intestinalis,. 
Cercomonas intestinalis (Lambl), Cercomonas coli (May), Tricho- 
monas intestinalis (Leuckart). 

The protoplasm is hyaline and finely granular, never containing 
solid inclusions, and with a very fine cell membrane. The nucleus is 
dumb-bell-shaped and at the base of the concavity. It has four pairs 




Fig. 74. — Trichomonas vaginalis. 



406 



CLINICAL DIAGNOSIS 



of flagella of almost equal length (9 to 14 microns), one on each side 
of the concavity, two pairs at the projection at the inferior edge of 
the concavity, and one^pair at the end. This parasite lives in the 
jejunum and the duodenum, and sits still on the top of a columnar 
cell, which it embraces with its concavity. In some cases they are 
found in such numbers that they form a membrane covering the 
mucosa. When they reach the large intestine they are encysted, and 
then are round or oval bodies with a very distinct membrane, within 
which is the folded organism. The motile parasite is thus not seen in 
the stools unless in a severe diarrhoea, in which case they have not 
had time to encyst themselves. They then move with some rapidity 
and very irregularly, lashing about in an aimless manner. They vary 
from 10 to 21 microns in length, and from 5 to 12 in width. The 



Fig. 75.— Lamblia intestinalis, showing the motile form in different positions, and stages of its encysting. 

X 900. 

encysted forms, from 10 to 14 microns long by 8 to 10 wide. The 
stools should be examined as fresh as possible and on a warmed stage. 
The number in the stools may be enormous, even estimated at eigh- 
teen millions in twenty-four hours. Their surest point in diagnosis 
is the concavity and the dumb-bell-shaped nucleus. The host is 
chiefly the mouse, rat, rabbit, dog, sheep, cat, etc. Men are evidently 
infected from water. They have been found principally in children. 
While their pathogenicity is uncertain, they may aid in the disease, 
and they certainly live best where there is intestinal trouble. 

We have recently had a case of marked infection in a medical 
ward, recognized in the stool by the encysted forms. When purged 
with Epsom salt the motile Lamblia was easily found. The egg-like 
encysted forms were present in the fatty stools in great numbers, 
from five to ten being present in most of the fields (400 x). It was 



THE FAECES 



407 



interesting to watch the organism encyst itself, first withdrawing its 
tail flagella, then becoming more oval, with the concavity last to dis- 
appear, from the edges of which the flagella projected until the cav- 
ity disappeared. In some cases the lines in the encysted form, com- 
monly taken to indicate the folds of the parasite, seemed the edges of 
this closed cavity. A membrane could in some be distinctly seen. 

Protomonadina, forms which have one or two equal or one prin- 
cipal flagellum and one or two smaller ones, are much smaller and of 
a lower class than the above mentioned polymastigina. Two of the 
three forms occur in man, Cercomonadidse, which have one flagellum 
and no undulating membrane, and the Trypanosomidse which have 
one flagellum and an undulating membrane which reaches the whole 
length of the parasite. 

Cercomonas Hominis. — These parasites are small flagellates 
occurring in the stools, from 10 to 12 microns in length, but varying 
from 8 to 16 microns. They are pear-shaped, with a long flagellum 
at the anterior end which may be even twice the body-length. They 
move very rapidly. Their pathogenicity is 
doubted. They have also been found in 
other parts of the body, including the 
sputum. 

Infusoria. — The infusoria are bilaterally 
symmetrical protozoans which have a per- 
manent shape, are ciliated, contain contrac- 

,•1 1 t 11 1 Fig. 76.— Balantidium coli. 

tile vacuoles, and usually a macro- and (Copied from Braun>) 
micro-nucleus. The order which is of most 

importance to us now is that of Heterotricha, which are uniformly 
ciliated, but with a border of longer cilia around the peristome, and 
of these, the Balantidium group. 

Balantidium coli or Paramecium coll — These parasites 
(Fig. 76) are oval, covered uniformly with cilia, are from 60 to 100 
microns long, from 50 to 70 broad, with the mouth at the anterior 
end, a funnel or cleft-shaped entrance extending one-fourth the body 
length and surrounded by cilia about twice as long as those over the 
body. The ectosarc and the endosarc are clearly differentiated. The 
latter is finely granular, containing many fat or mucous droplets, 
starch granules, even red blood-corpuscles, leucocytes, and bacteria. 
The nucleus is kidney- or bean-shaped and also accompanied by one 
or more accessory nuclei. Usually there are two contractile vacu- 
oles which pulsate feebly. The surface is traversed by parallel lon- 
gitudinal lines connecting the two poles, most distinct at the anterior 
end. The anal orifice is at its posterior end, which is rather blunter 
than the anterior. This parasite occurs especially in the colon, but 
in severe cases may be found even in the jejunum, and may be present 




408 



CLINICAL DIAGNOSIS 



in the stools in some cases in enormous numbers, even from one to 
two hundred in one drop. The blood-stained mucus should be ex- 
amined, which also contains many epithelial cells. The pathogenicity 
of these parasites has been questioned, and yet it is now quite unani- 
mously granted that they may be the cause of the most severe and 
stubborn catarrh, which may even be fatal. Others say they invade 
a catarrhal intestine as secondary parasites ; others say they may set 
up a catarrh which continues after they die out (Henschen). Be- 
tween eighty and ninety such cases are now on record, especially from 
Russia. A very good description is that given by Strong and Mus- 
grave. 13 Klimenko 14 concludes that the diarrhoea may first be due 
to their mechanical irritation of the rectal mucosa, later to catarrhal 
or even ulcerative colitis ; that they invade the intestinal wall, enter 
the blood-vessels, and sometimes cause emboli to distant organs; but 
that their action and effect are chiefly mechanical is shown by the ab- 
sence of any degenerative or inflammatory changes which would 
point to a toxine. 15 

We have seen these parasites in a few cases of diarrhoea, but in 
none severe enough or in numbers great enough to attach much im- 
portance to their presence. 

Enthelmintha. Trichina Spiralis. — The adults or the embryos may be in 
the stools, but they are rarely found. Adults occur in intestines of rats, pigs,, 
dogs, and cats. The male worm is from 1.4 to 1.6 mm. long and 0.04 mm. 
wide, the female 3 to 4 mm. long by 0.06 mm. wide. After the encysted em- 
bryos are swallowed with meat the capsule is digested in the stomach and the 
embryos rapidly mature in the intestine. On the second day the males die and 
the females bore their way into the mucosa of the villi, or at the base of the Lieber- 
kuhn glands, at which point they lie in the lymph spaces and viviparously hatch 
the young (0.09 to 0.1 mm. long, 6 microns wide) into the lymph and blood-stream. 
These in nine or ten days begin to take their permanent habitat in the muscles, 
travelling passively in the blood-stream and also actively boring their way. They 
are then about 1 mm. long. A capsule is formed around them, and in about one 
year this begins to calcify. (See Fig. 72a, page 402.) 

Ascaris lumbricoides. — This, the ordinary " round worm," is 
a common intestinal parasite, occurring in about 0.4 per cent, of all 
cases (Garrison, Ransom, and Stevenson). The female is from 20 to 
40 cm. long, 5 mm. thick, the tail straight and conical. The male 
is from 15 to 25 cm. long and 3 mm. thick. The posterior end is 
bent ventrally into a hook, and terminates in the two spicules. The 
mouth of both is surrounded by three papillae. The color of these 
worms is gray or a dirty reddish-brown. While it is an inhabitant of 
the small intestine, and hence is most commonly seen in the stools» 

"Johns Hopkins Hosp. Bull., February, 1901. 

14 Beitr. z. path. Anat. u. allg. Path., 1903, Bd. 33, p. 281. 

15 Ehrnrooth, Zeitschf. f. klin. Med., 1903, vol. xlix. p. 321. 



THE FAECES 



409 



yet it is often present in the vomitus. Its eggs (Fig. 75, d, c) are found 
in the stools in large numbers. These are elliptical, 50 to 70 microns 
long and 40 to 50 microns wide. Those which we have measured 
varied from 65 to 80 by 45 to 55 microns, including the envelope, 
and 59 to 72 by 40 to 50 microns not including this. These eggs 




Fig. 77. — Oxyuris vermicularis. A, B, and C, adults; A and C are females full of eggs. X 12. 

D, egg, X 400. 

have an unsegmented protoplasm surrounded by a thick transparent 
shell, which in turn is covered by a thick, gelatinous very uneven, 
lumpy envelope, which is usually bile-stained. This envelope may 
be lost, in which case the smooth-shelled egg has been mistaken for 
the uncinaria. In the diagnosis of this worm it is to be recommended 



410 



CLINICAL DIAGNOSIS 



that santonin be given, which will have a therapeutic as well as a 
diagnostic value. These worms occur in children especially. Few 
are present, as a rule, although very many in some cases. 

Smith and Goeth 16 consider the worm they report a new species, 
— " Ascaris texana." 




Fig. 78.— Ankylostomum duodenale, natural size to right, much magnified male on left. 

(From Braun.) 

Oxyuris Vermicularis. — This little parasite (Fig. 77) occurs 
in the rectum and colon even as high as the caecum where it in- 
habits the appendix, but it may even reach the stomach. It can travel 
16 Jour. Am. Med. Assoc., 1904, No. 8. 



THE R/EGES 



411 



through uterus and tube to Douglas's cul-de-sac. According to 
some, it can bore its way through the intestinal wall and cause an 
abscess. It is present in perhaps 0.8 per cent, of adults. The adult 
male is from 3 to 5 mm. long, with its posterior end bent into a 
ventral hook. The female is 10 mm. long and 0.06 mm. wide. 
They are white in color. Their eggs are 50 microns long and 16 to 
20 microns wide, and have a characteristic asymmetry. The para- 
site leaves the rectum to lay its eggs on the skin surrounding the 
anus, at which time the itching occurs. The eggs when deposited 
already contain a well-developed embryo. It is rare to find the eggs 
in the stools, except in the mucus which the stool gains on passing 
through the lower rectum, hence the skin around the anus should be 

^bipartite 




Fig. 79.— Caudal bursa of Uncinaria americana. (Schematic.) 

examined for the adults. It is only accidentally that eggs are found 
except by scraping the surface epithelium from the margin of the 
anus, and this is the best method. 

Very good plates of the development of this worm are given by 
Heller. 17 

Uncinaria Duodenal is and Uncinaria Americana. — These two para- 
sites (Figs. 78-84), belonging to the nematode family, Strongyloidae, 
are the cause of some of our severest anaemias. They have recently 
attained great importance in this country through the demonstration 
by Stiles that they are the common cause of the " anaemia of the 
South." In five hundred cases chosen at random they were present 
in 3 per cent. 18 They have long been known in their connection 
with bricklayer's anaemia, tunnel-workers' anaemia, Egyptian chloro- 
sis, miners' anaemia, etc. The best description of these parasites is 
that given by Stiles in the Eighteenth Annual Report of the Bureau 
of Animal Industry, 1901. 

Uncinaria Duodenalis, Ankylostomum Duodenale. — The 
body is cylindrical, somewhat attenuated anteriorly. The buccal 

17 Deutsch. Arch. f. klin. Med.. 1903, Bd. 77, p. 21. 
18 See also Smith, Am. Jour. Med. Sci., 1903, vol. cxxvi. 



412 



CLINICAL DIAGNOSIS 



cavity (Fig. 82) has two pairs of ventral teeth curved like a hook and 
one pair of dorsal teeth directed forward; the dorsal rib does not 
project into the cavity. The male is from 8 to 11 mm. long with a 
caudal bursa (Fig. 80) with dorso-median lobe, and prominent lateral 
lobes united by a ventral lobe. The dorsal ray divides at a point 




Fig. 80. — Caudal bursa of Uncinaria duodenalis. (Schematic.) 



two-thirds its length from the base, each branch being tridigitate. 
The spicules are long and slender. The female is from 10 to 18 mm. 
long, the vulva at or near the posterior third of the body. The eggs 
are ellipsoid, 52 by 33 microns, laid in segmentation. Development 
is direct without intermediate host. 

Uncinaria Americana (Stiles, 1902). — This differs from the 




Fig. 81— Head of Uncinaria americana. Fig. 82.— Head of Uncinaria duodenalis. 

(Schematic.) (Schematic.) 



above-mentioned form in that its buccal cavity (Fig. 81) has a 
dorsal pair of prominent semilunar plates or lips, and a ventral pair 
of slightly developed lips of the same nature, no hook-like teeth. 
The dorsal conical median tooth projects prominently into the buc- 
cal cavity. The male is from 7 to 9 mm. long, the caudal bursa 
(Fig. 79) with a short dorso-median lobe, which often appears as 
if divided into two lobes, and with prominent lateral lobes united 



THE FiECES 



413 



laterally by an indistinct ventral lobe. The common base of the 
dorsal and dorso-lateral rays is very short. The dorsal ray is divided 
to its base, its two branches being prominently divergent and their 
tips bipartite. The spicules are long and slender. The female is 
9 to 1 1 mm. long, the vulva in the anterior half of the body but near 
the equator. The eggs are ellipsoid, 64 to 72 by 36 to 40 microns, 




a bed 

Fig. 83. — Eggs of Uncinaria duodenalis. a, unsegmented ; b, with four segments and showing nuclear 
spindles ; c and d, later stages of segmentation. X 400. 



in some cases partially segmented in utero, in other cases contain- 
ing a fully developed embryo when laid. 

The eggs (Fig. 83) of the Uncinaria worms are found in the 
stools either unsegmented or during the early stages of segmenta- 
tion. They have a thin clear shell. While the yolk will show all stages 
of segmentation, it is rare to find eggs with an undivided yolk, those 




Fig. 84. — Embryo of Uncinaria (americana ?) found in the stool. X 400. 

divided into four, eight, sixteen, or more segments being the most 
common. The eggs should be searched for in the faeces, a small 
amount being mixed in a drop of water and spread on the slide. The 
older the faeces and the warmer the weather the more advanced will 



414 



CLINICAL DIAGNOSIS 



the segmentation be. Of Uncinaria americana it is more common 
to find the fully developed embryo within the egg-shell or free. 

It is well in a suspected case to allow the stool well mixed with 
water to sediment, or to centrifugalize it; the eggs will be found at 
the bottom. The adults may be found in the sedimented stool after 
a small dose of thymol followed by oil. The adults are usually 
red from the blood with which they are filled. They occur in the 
duodenum, jejunum, and ileum, many thousands sometimes in one 
person, although, as a rule, not more than a few hundred. While 
they do not multiply in the intestine they may live there for five 
years. They cause a severe chlorotic anaemia. 

Stiles suggested the simple test of placing a small portion of stool 
on white blotting-paper and allowing it to stay for an hour or 
longer. On removing it a reddish-brown stain remains. 



FlG. 85.— Distoma lanceolatum. a, adult; b, egg with embryo ; c, empty shell. (From v. Jaksch.) 



Trichocephalus Trichiuris. Trichocephalus Dispar. 
Trichiuris Trichiura. — This is the ordinary whip-worm, a worm 
from 4 to 5 cm. long, with two-thirds of the length a whip-like tail. 
They occur especially in the caecum, but also in the colon ; rarely 
in the small intestine. They are perhaps one of the most common 
of intestinal parasites, in 10.3 per cent, of adults in this country, 
but in the stools of 45 per cent, in some parts of Germany, and 
at autopsy in 100 per cent, in Southern Italy. Their eggs (Fig. 73) 
are very characteristic, being from 50 to 54 microns long and 23 
microns wide, with an unsegmented yolk and a very thick shell, 
into each pole of which is inserted a plug. These eggs present an 
interesting variety of colors, some being light lemon-yellow, some 
deep yellow and some a dark brown. In the stools we have also found 
eggs which were certainly those of this worm, but which had no 




a 



c 



THE PVEGES 



415 



plugs at the end. These may be very young eggs, since they have 
this shape. This parasite is harmless as a rule, but may cause 
enteritis and the severest and even fatal anaemia. In a recent review 
of the effect of this worm, Becker 19 classifies the symptoms as gastro- 
intestinal, diarrhoea due to ulcers or catarrh, blood in the stools, symp- 
toms of appendicitis even; nervous symptoms simulating meningitis 
(Erin thought beriberi due sometimes to this worm) ; and anaemia with 
all its symptoms. 

Strongyloses Intestinalis. — Anguillula stercoralis et intesti- 
nalis ; Leptodera stercoralis et intestinalis ; Rhabditis stercoralis, Rhab- 
domena strongyloides, are a few of the many synonyms. The rhab- 
ditiform larvae of this parasite found in the stools measure from 0.3 to 
0,6 mm. long and from 16 to 22 microns wide. They are in very 
active motion. The best way to find them is to make a depression in 
the fecal mass, fill it with water, place the stool then in a thermostat, 




Fig. 86.— Taenia solium : Head (magnified), proglottis (actual size), and egg (magnified). 
(Zeiss's eye-piece IV., objective IV.) (From a preparation by Cori and v. Jaksch.) 

and examine a drop of this water the next day for the eel-like worms. 
The eggs do occur, but very rarely, and could hardly be distinguished 
from those of Uncinaria duodenalis, but they are perhaps a little larger, 
measuring from 65 to 70 microns long and from 34 to 39 microns 
wide, and are very much segmented. In the intestines all stages of 
the development of the embryo may be followed. 

The adult female resembles a filaria; it measures from 2.1 to 2.2 
mm. long and 32 to 39 microns wide. The body increases slightly 
and gradually in size from the head to the posterior quarter, and 
then terminates rather suddenly in a short tail. The male is about 
one-fifth smaller. 

The worms are abundant in the duodenum, fewer in the jejunum. 
The adults are found very rarely in the stools. They occur in about 
0.6 per cent, of all persons. 

"Deutsch. med. Wochenschr., 1902, June 26. 



416 



CLINICAL DIAGNOSIS 



Trematodes Eggs of Distoma lanceolatum and Distoma hepat- 

icum have been found, but rarely, in the stools. Those of Distoma 
lanceolatum are yellowish when young, dark brown when older, 
from 38 to 45 by 22 to 30 microns in size. They have a thick shell 
with a lid, and contain a ciliated embryo. Those of Distoma hepat- 
icum (Fasciola hepatica) are yellowish-brown, oval in shape, and 
from 130 to 145 microns long by from 70 to 90 microns wide (see 
Fig. 85). 

Cestodes. — In a suspected case of tape-worm it is always important 
that segments be seen before the treatment, which is severe, is under- 
taken. We have had sent to this clinical laboratory, for instance, 
mucous casts of the intestine under the supposition that they were 
decomposing tape-worms. Certain food constituents are also thus 
interpreted. To determine the success of treatment the head should 
be searched for; the stool is well mixed with water and allowed 
to settle for ten minutes, and then the upper fluid decanted ; this is 
repeated several times ; the heavy head will settle to the bottom. 
If the head is not found a cure is not certain till three months have 
passed without the reappearance of segments. 

Taenia Solium. — The infection is derived from Cysticercus cellulosae of 
pork. The adult worms in the intestine average about 3 m. long, although much 
longer have been described ; the head varies from 0.6 to 1 mm. in diameter, with 
four suckers from 0.4 to 0.5 mm. in diameter, and a rostellum with a double 
crown of 22 to 32 hooks from 0.11 to 0.18 mm. long. The neck is about 3 cm. 
long, and is unsegmented. The ripe segments are from 9 to 10 mm. long, by from 
4 to 5 mm. wide. The genital openings are at the margin and arranged in a fairly 




Fig. 87. — Head of Taenia saginata. X 5- 

regular alternating manner. The uterus is characteristic, consisting of a large 
median stem and on each side from seven to ten coarse branches, each one of 
which branches dendritically. The eggs are round or oval, the shell very thin 
but surrounded by an embryonic shell which is thick, with radiating lines, and 
often yellow in color. These eggs are about 35 microns in diameter. This worm 
is excessively rare in America. Very few cases have been found here, and those 
exhibited in museums are mostly wrongly labelled (Figs. 86 and 89 A). 

Taenia Saginata. — The beef tape-worm, the infection arising 
from the cysticercus of beef and, perhaps, of sheep, is in this coun- 
try quite common. The adult worm varies from 4 to 8 m. or more 
in length. The head (Fig 87) is from 1.5 to 2 mm. in diameter, 



■A, ripe link of Taenia saginata. X 3. B, four unripe links. 




Fig. 89.— Eggs of Taenia saginata X 400. 




Fig. Sqa. — Taenia solium. Mature links from a case recently discovered in the Johns Hopkins Out- 
patient Department. (Kindness of Dr. T. R. Boggs). 



THE FAECES 



417 



cuboid in shape, with four suckers each 0.8 mm. in diameter, and 
without hooks. The neck is long- and delicate. The ripe segments ( Fig. 
88) are from 16 to 20 mm. long by from 5 to 7 mm. wide. The over- 
ripe segments are longer and somewhat more slender. The genital 
openings are at the margins and irregularly alternate. The uterus 
is characterized by the multitude of its fine branches, from twenty 
to thirty-five on each side of the median stem, which branch dicho- 
tomously. The eggs (Fig. 89) are spherical, with a thin shell sur- 
rounded by the embryonic shell which is thick and radially striated, 




FlG 9 o — Hymenolepis nana. Adult (left), head (right), egg (above) ; a, hooklet. (From Braun.) 

transparent, oval, from 30 to 40 microns long by from 20 to 30 
microns wide. 

Hymenolepis Nana. Taenia Nana. — This is a dwarf tape- 
worm not at all uncommon in man, as Stiles 20 has shown who found 
it in sixteen of three thousand five hundred persons. 

The worm (Fig. 90) is from 10 to 15 mm. long, from 0.5 to 
0.7 mm. broad, with four suckers and a row of twenty-four to 
thirty very small and characteristically shaped hooks (14 to 18 mi- 

20 New York Med. Journ., 1903, vol. lxxviii. p. 877. 

27 



418 



CLINICAL DIAGNOSIS 



crons long) on the spherical head, which is 0.25 to 0.3 mm. in diam- 
eter. The segments, about one hundred and fifty in number, are 
short (14 to 30 microns) and relatively broad (0.4 to 0.9 mm.). 

The egg is characteristic; it is spherical or oval, 30 to 37 by 48 
microns in diameter, having two distinct thick membranes, each pole 
of the inner having a more or less conspicuous process with filamentous 
appendages. 

The parasite inhabits the ileum, where a few or many thousands 
may be present. It is probably the same as the very common form 
in rats. 

Dipylidium Caninum. Taenia Cucumerina. — This tape-worm is from 15 to 
35 cm. long, from 1.5 to 3 mm. broad, the head club-shaped with rostellum and three 
or four rings of hooklets. The eggs are circular, from 43 to 50 microns in diam- 
eter, with thin shell. It occurs in dogs, cats, and rarely in man, and then especially 
children. 





Bothriocephalic Latus. — This tape-worm (Fig. 91), the 
largest parasite of man, is exceedingly common in the maritime coun- 
tries of Europe, in Ireland, and in Japan. 
The cysticercus stage occurs in fish. A 
rapidly increasing number of cases is be- 
ing discovered in America. A very good 
report is that of Willson. 21 This tape- 
worm is often 8 m. in length and in some 
cases has reached even fifty feet. The in- 
fections are often multiple. In Willson's 
case there were two worms with an aggre- 
gate of eighty-two feet. In the multiple 
infections with fifty to one hundred worms 
the individuals are much shorter, some- 
times from three to five feet long. The 
head is 1 mm. broad, from 2 to 3 mm. long, is flat, almond- or spoon- 
shaped, with two deep grooves at its sides which serve as suckers. 
It has very little neck. The ripe segments, which begin about 50 cc. 
from the head, increase in size until about 10 to 15 mm. broad and 
3 to 4 mm. long. The genital opening is on the side, not the edge, 
and around it the uterus is arranged as a rosette. The distribution 
of these organs is more regular than that of the septa of the seg- 
ments, Willson considering the imperfect or abortive segments very 
characteristic of this family of worms. The' eggs are characteristic. 
They have a thin shell, the contents coarsely granular, mulberry-like, 
and a lid which may be open or closed. In very young eggs the 
lid cannot be seen, and in older may be rendered evident by pressure 



Fig. 91.— Bothriocephalus latus. 
(From Braun ) 



21 Amer. Jour, of Med. Sci., 1902, vol. cxxiv. 



THE F^EGES 



419 



on the glass. Their size is 70 by 45 microns. The eggs are im- 
portant in diagnosis, since the segments occur only at certain times, 
although when they do occur it is in abundance. The most interesting 
thing about this enormous tape-worm is the production in certain 
of the hosts of an anaemia which hsematologically cannot be distin- 
guished from primary pernicious anaemia. Only a small percentage 
of cases which harbor the worm have this anaemia, and they recover 
rapidly when the worm is removed. Various reasons are given for 
the good health some hosts enjoy, — heredity, lack of predisposing 
causes, etc., while Dehio thinks the worm to be harmful must either 
die or at least be diseased. The cause of the anaemia is pretty cer- 
tainly a toxine affecting the blood and perhaps the bone marrow. 



Fig. 92a. — Egg of Schistosoma haematobium found in stool. Fig. 92b. — Eggcf Schistosoma hasma- 



The eggs of Schistosoma haematobium (see page 305) may also 
be found in the stools. It is interesting to note the number with the 
spine lateral and those with it terminal. 

Plant Parasites. — Yeasts are often present in normal stools. 
Moulds are rare. The Oidium albicans has very rarely been found 
in children. SarcintE are often found in cases of dilated stomach, 
and, indeed, may lead to a diagnosis of this condition. They occur 
in other conditions also. When present in large numbers they may 
aggravate a diarrhoea by the products of their fermenting processes. 
They are the same as Sarcina ventriculi. 

Bacteria. — Bacteria form no small part of the mass of the stools 
(see page 386), the vast majority of these organisms are dead. 
Almost any organism may appear accidentally in the intestine but 
there is a flora of bacteria so constantly found that their presence may 
be considered normal. Among these are: Bacillus coli communis 




Embryo dead. X 400. 



tobium found in stool. Embryo alive. 
X 400. 



420 



CLIXICAL DIAGNOSIS 



(see page 288), Bacillus lactis aerogenes (see page 289), and for the 
suckling, Bacillus bifidus. 

Bacillus bifidus (Teissier, Paris Thesis, 1900). — This organism 
(see Fig. 92c) would appear to be a normal inhabitant of the intes- 
tines of the suckling, and to disappear soon after the child is weaned. 
When, however, it persists, its presence would seem to be associated 
with certain symptoms of intestinal intoxication. It is an organism 
from 2 to 4 jt* long, and often in pairs. Its most characteristic shape 
is like the letter Y. Involution forms are common. The greatest 
interest to us is that this is one of the few intestinal organisms which 
is not decolorized by Gram's method. It is a strict anaerobe. Among 
other important organisms are. Bacillus alkaligenes ( see page 290), 
and the proteus group (see page 290). Among the important patho- 




Fig. 92c. — Bacillus bifidus. (Photomicrograph by Dr Thomas M. Wright.) 

genie organisms which sometimes, even frequently, are found, are 
Bacillus pyocyaneus (see page 290), Bacillus aerogenes capsulatus 
(see page 290), Bacillus tetani (see page 291), the Staphylococcus 
group (see page 291), and the Streptococcus group (see page 292). 
A great many of the thermophilic and the acidophilic organisms are 
present, and they were recently described as the predominating organ- 
isms among those which were supposed to be dead since they would 
not grow on ordinary media, or at ordinary temperature. (The ther- 
mophilic organisms grow only at temperatures above 40° C. and some 
of them best at 60 0 C. They cannot therefore multiply in the intestine 
and those found in the stools must be swallowed with the food. ) The 
present opinion is that the lower bowel at least is not a favorable 
habitat for organisms and that the most in the stools are dead. 

Tubercle Bacilli. — In a search for these it is useless to digest 
a solid stool. Mucous masses should be selected, especially the blood- 



THE FAECES 



421 



stained or purulent particles, and these treated as in sputum. In 
class work it is interesting to note how many some find who select 
the particles with care, and how many students find none. In intes- 
tinal tuberculosis they are often present, and yet in cases in which 
they would be most expected none are found, hence the probability 
is that many are destroyed. Again, when found, the possibility of 
their origin from swallowed sputum must always be thought of, and 
the diagnosis of pulmonary tuberculosis has been made in this way, 
especially in children ; but this is rather a remote possibility in the 
case of a careful adult. 

Page's method of searching for the bacilli in the solid stool is to 
suspend a piece half the size of a pea in 1.5 cc. of distilled water, 
add 54 cc. of a mixture of equal parts of absolute alcohol and ether, 
and centrifugalize for ten minutes; a smear made of the sediment 
is fixed to the slide with a drop of egg albumin, and stained as 
usual. 

Stools in Disease — In typhoid fever the stool most characteristic 
is of " pea-soup" appearance, copious, watery, of foul odor, alkaline 
reaction, with many triple phosphate crystals. But in clinics which 
limit these patients to a rigid milk diet, diarrhoea is less common 
than constipation. The stool is frequently blood-tinged, this tingeing 
sometimes warning us of a coming hemorrhage. Pus (microscopic) 
is rare except in severe cases with extensive ulceration. 

Bacillus Typhosus. — Many methods have been proposed for grow- 
ing this organism from the stools. We give the one which is most 
trusted. 

Drigalski and Conradi's medium.* 

Three pounds of minced beef are mixed with 2 litres of water and allowed 
to stand over night. The beef is then pressed, the beef juice is boiled for one hour, 
filtered, and to this filtrate are added 20 gms. of peptone (Witte), 20 gms. of nutrose 
and 10 gms of sodium chloride. It is then boiled again for one hour and filtered. 
To this filtrate are aded 60 gms. of the best agar. It is then boiled for three hours 
(one of which is in the autoclave). The fluid is made faintly alkaline to litmus, 
filtered, and then boiled for one-half hour. While hot the next solution is added. 

The litmus solution is made by boiling 260 cc. of litmus solution for 10 minutes, 
adding 30 gms. of the purest lactose and boiling again for fifteen minutes. This 
litmus-lactose solution is now added while boiling to the hot agar solution mentioned 
above. The mixture is then well shaken and then made very faintly alkaline. 

One then adds 4 cc. of a hot sterile 10 per cent, solution of soda and 20 cc. 
of a freshly prepared 0.1 per cent, solution of Krystallviolett B., Hochst, in warm 
sterile distilled water. 

The resulting medium is a beef juice-nutrose-agar-lactose-litmus solution which 
contains 0.01 p. M. Krystallviolett. It hardens to a very firm mass. It is firm 
enough to prevent much diffusion of the acid formed. It does not become dry. 
The lactose is split by Bacillus coli, not by Bacillus typhosus. The colonies of 
colon bacilli will therefore turn red, the typhoid blue (since this organism splits off 
basic bodies from the proteids). Krystallviolett will inhibit the growth of many 



* Zeitschr. f. Hyg. u. inf. Krankh., 1902, xxxix, 283. 



422 



CLINICAL DIAGNOSIS 



other organisms, especially acid-producing cocci. The medium is poured at once 
into large Petri's dishes or kept in 200 cc. flasks. 

These authors recommend to inoculate several series of plates in 
order to get the largest possible number of isolated colonies on a plate. 
If the stool is fluid one series of plates is inoculated with the undiluted 
stool, another with the stool diluted with 10 to 20 volumes of sterile 
normal salt solution. If the stool is solid it should be rubbed up to a 
homogeneous mass with sterile salt solution and various dilutions of 
this used. 

The stool is rubbed on the surface of the medium. After inocula- 
tion the plates are left open for at least half an hour to allow the 
surface to dry, otherwise the colonies will coalesce (the Krystallviolett 
will kill any air contaminations). When dry the plates are put into 
a thermostat at 37 0 C. The plates are examined in from 14 to 24 
hours. The colon colonies will vary from 2 to 6 or more millimetres 
in diameter, they are of a great variety of shades of red in color and 
are opaque. The paratyphoid colonies are sometimes red, sometimes 
blue (see page 289). 

The typhoid colonies have a diameter of from 1 to 3 mm., are 
blue or violet in color, glassy, not doubly refractile, seldom opaque. 

The colonies of the Bacillus subtilis group are also blue, but are so 
much larger than the typhoid that error is seldom possible. In some 
fetid stools the blue colonies of Proteus, Bacillus fluorescens and 
Bacillus fcecalis alkaligenes may deceive. They are rare and can be 
distinguished by the agglutination test. 

Drigalski and Conradi were able to obtain the typhoid bacilli in 
every case of typhoid fever examined. Pratt, Peabody and Long 
(Jour. Am. Med. Asn., 1907, xlix. 846) were not able to find it in 
nearly all their cases and believe most stools to contain very few. 

In severe Asiatic cholera the rice-water stools are quite charac- 
teristic. These are copious, the water being in good part secreted by 
the intestinal wall with small gray flecks which are masses of epithelial 
cells, cholera spirilla, and fat droplets. They have no fecal odor, are 
alkaline, almost alcoholic, sometimes are blood-stained, contain little 
albumin and much salt. 

Spirillum Cholera Asiaticcc. — The spirillum of Asiatic cholera, or 
the " comma bacillus," is a small curved " comma-shaped " bacillus 
about 2 /x long and 0.5 fi thick. It is very actively motile, and has a 
single long delicate flagellum at one end. It does not produce spores. 
Involution forms are common. It stains readily in all bacterial stains 
and decolorizes by Gram's method. This organism grows very rapidly 
at room temperature on all ordinary media, and in some so poor in 
nourishment that other organisms cannot grow in them. It will not 
grow on potato at room temperature, but will in a thermostat. It is 



THE MECES 



423 



a very aerobic organism. It grows in a fairly characteristic manner 
on gelatin, which it liquefies. In gelatin plates the colonies soon 
appear as minute white points which resemble fragments of broken 
ground glass with granular irregular margins. Then liquefaction 
begins and the colony sinks in the little cup of liquid cloudy gelatin 
which forms a halo around it. This organism produces much indol. 
It is very sensitive to acids. 

Other and non-pathogenic spirilla are very common. There is one 
in the mouth which will not grow in ordinary media. Over sixty non- 
pathogenic species with similar morphology, but different cultural 
characteristics, have been found in various drinking waters (e.g., 
Spirillum schuylkiliensis) . 

Many pathogenic forms have been described : MetchnikofFs spi- 
rillum was found in an epidemic in chickens, is pathogenic for birds 
(the true cholera spirillum is not), and is a more rapid grower than 
the latter; Massea's spirillum (very pathogenic to pigeons and with 
four or five flagella) ; Finkler and Prior's form, from a case of cholera 
nostras (grows as a dirty brown scum on potato at room tempera- 
ture) ; Deneke's form from old cheese (will not grow on potato). 

But morphology and cultural characteristics are not sufficient for 
the recognition of these organisms. The specific test must also be 
positive. A guinea pig is immunized to a given species of the spi- 
rillum. A little of the organism in question is then injected into the 
peritoneal cavity. If the organism injected is the one to which the 
animal is immune, those in the pleural cavity will be rapidly destroyed. 

The diagnosis of Asiatic cholera may (25 to 30 per cent, of the 
cases in some epidemics) be made directly from the stools. A smear 
will show vast numbers of these comma-bacilli. 

Usually it is necessary to inoculate gelatin and agar plates with 
" rice particles" of the stool and in 24 hours (if grown on gelatin 
at 22 0 C) the typical colonies are found. When there are but few 
organisms present the enriching method of Schottelius is used. If a 
little of the stool is well mixed in a large amount of bouillon, a surface 
scum of these spirilla will form, from which cultures may be made. 

To demonstrate this or similar organisms in water, add to 90 cc. 
of the suspected water 10 cc. of a sterile solution of 10 per cent, 
peptone and 5 per cent, of sodium chloride. This is now placed in a 
thermostat and the scum examined. 

In dysentery, rectal diarrhoea, and cancer of the rectum, the move- 
ments are frequent and scanty. They soon lose their fecal character 
and become mucoid, mucopurulent, hemorrhagic or sero-hemorrhagic, 
the amount of blood separating the cases of " white " from " red " 
diarrhoea. Sometimes fragments of necrotic mucous membrane or 
of cancer are found ; often masses of bloody mucus. 



424 



CLINICAL DIAGNOSIS 



In amoebic dysentery during the acute exacerbations there is diar- 
rhcea of from three to six movements a day containing bloody mucus 
in which may be found the amoebae; the stools are thin and watery, 
their odor offensive. These periods are separated by others of even 
years' duration, with normal movements, or constipation, and yet here 
the amoebae may be found if looked for. It is in these cases that the 
routine examination of the stool is important, even in cases without 
symptoms referable to the liver, as was seen in a recent case of con- 
stipation and irregular fever without hepatic or intestinal features. 
At autopsy a large amoebic abscess of the liver was found. 22 

Pancreatic Disease. — Fatty stools are common (see page 390), yet 
this must be confirmed by other signs of pancreatic disease. A large 
amount of muscle- fibre (Azotorrhcea) in a case without diarrhoea is 
a valuable sign; a reduction of ethereal sulphates in the urine is a 
point in favor, yet alone is of little value ; yet all together are of value 
in a case without jaundice and with other signs of pancreatic disease, 
as abdominal tumor, glycosuria, etc. In some cases of diabetes the 
stool is pure fat, in amount from a few drachms to a cupful of pure 
yellowish-brown fat; in others about 30 per cent, is fat. Naunyn 
knows of no case of true fatty stools in diabetes without pancreatic 
disease. 

For Sahli's test of the efficiency of pancreatic juice, see page 385. 

A recent method highly recommended is the use of pancreon, 
which preparation is not affected by the gastric juice. In a case with 
much muscle in the stool and no diarrhoea, if pancreon be given and 
the muscle diminish, it is in favor of pancreatic disease. 

Some {e.g., Ury and Alexander) 23 would base the diagnosis on 
fatty stools, many muscle-fibres in a fairly solid stool, and failure of 
jaundice. The suspicion is especially justified if a large amount of 
fluid fat separates itself from the rest of the stool. The simultaneous 
presence of glycosuria is rare, the absence of decomposition is not 
usual, nor should it be expected since there is so much albumin present, 
but the simultaneous steatorrhea and azotorrhoea is important and 
with diabetes conclusive. 

And yet in pancreatic disease azotorrhoea may wholly fail. Again, 
steatorrhoea alone is not very important, for with complete atrophy of 
the pancreas this may persistently fail, and if present it may be due 
to a long list of diseases affecting fat absorption as well as fat splitting. 
And in some cases with increased fat the per cent, split is normal. 
All will agree that stool examination is of little value unless the patient 
has been on a constant diet of known composition. As yet not enough 
work has been done to detect more than gross variations. The assimi- 

22 See also Councilman and Lafletir, Johns Hopkins Hosp. Rep., vol. ii. p. 395. 
23 Deutsch. med. Wochenschr., 1904, No. 36. 



THE F.ECES 



425 



lation limit for fat in a normal case is abont 350 gms. of butter; of 
this the loss is not over 7 to 10 per cent.; jaundice or acholia due to 
other diseases must not be present ; the fat should not be emulsified ; 
any diarrhoea should be checked with opium when making such 
alimentary tests. 

Permanent Mounts of Small Worms. — For the following 
methods I am indebted to Dr. Thomas R. Boggs. 

Boggs' Method. — The worm is allowed to die in water (that it 
may be fixed while in a relaxed condition). It is then spread out on 
a piece of filter paper and immersed in an alcohol-glycerin cleaning 
fluid (alcohol, 80 per cent., 16 parts, and glycerin 4 parts). The 
specimen is allowed to remain in this solution in an open dish loosely 
covered with cloth or paper, until the alcohol has entirely evaporated 
off. This may take from two to six weeks. Since the worm is spread 
out on the filter paper it will contract but little. Should it do so it may 
be slightly pressed between slides held together by rubber bands. 
When the specimen is sufficiently clear it is gently blotted on the 
slide and covered with melted glycerin- jelly. The coverslip is then 
dropped on and if necessary pressed down until the jelly has hardened. 
After the jelly is hard the excess is removed from the borders of the 
cover and the edges sealed with microscopic cement or asphalt paint. 

The glycerin jelly is made by melting 14 grammes of the best gold mark 
gelatin in 120 cc. of hot water, and adding 120 cc. of glycerin. This is then 
cooled to 50 0 C. The carefully separated whites of two eggs are then added and 
the fluid heated gently without stirring. This is then filtered, the volume made up 
by adding water to 240 cc, and 1 cc. of pure carbolic acid is added. This jelly is 
solid at ordinary temperatures, but is easily melted under the hot water tap. 

To Preserve Stools Containing Parasite Eggs. — The stools 
are diluted to a soup-like consistency and then one-tenth volume of 
formalin is added. The specimens are then kept in a tightly corked 
bottle. Parasite eggs and larvae will keep fairly well preserved. 

Stained Specimens of Worms. — The worm, as fresh as possible, 
is fixed in a boiling saturated alcoholic solution of mercuric chloride 
for from 10 to 30 minutes, depending on the thickness of the speci- 
men. It is then washed in running water over night, and then in 
water containing a trace of tincture of iodine until it is free from 
mercury. The specimen is then heavily overstained (for from 12 to 
24 hours) with hematoxylin or carmine, and decolorized with acid 
alcohol, under the lower power of the microscope, until the desired 
color is obtained. The specimen is then washed, dehydrated in alcohol, 
cleared in oil of cloves or creosote, and mounted in Canada balsam. 
This method is best for the study of the minute anatomy of tape 
worms and flukes. It is not so successful with round worms. 



CHAPTER V 



THE BLOOD 

Obtaining the Blood. — A simple sharp-pointed lancet is necessary, 
or a needle with a cutting edge. Of the latter there are on the market 
several with a bayonet point. A good instrument is the ordinary 
Hagedorn needle, which the surgeons prefer for blood work. If 
nothing better is at hand, an ordinary steel pen, one nib of which is 
broken off, will do excellently. The one thing to remember is that 
the point should have a cutting edge, and not be round and sharp, not 
too long and slender, as is so often the case. There are on the market 
also holders in which separate needles can be inserted. These can be 
thrown away when dull, thus obviating the necessity of sharpening the 
instrument. Special forms have been invented, some with the needle 
on a spring which forces it to a certain depth, as, for instance, 
Francke's needle, which is quick and painless, and is to be recom- 
mended to those who cannot train themselves to give a sharp, quick 
blow. In another form the needle projects from a holder which 
serves as a guard, and hence, no matter how hard a blow is given, 
can penetrate only a certain distance. An illustration of this is the 
Daland needle. We prefer, however, a simple instrument, any needle 
with a cutting edge ; and if the hand be at all trained, a puncture can 
be made deep enough to get as much blood as is necessary. 

If considerable blood is desired, a hypodermic syringe should be 
used. A tight bandage is tied around the upper arm, and then a 
towel wet with warm bichloride wrapped around the elbow-joint, which 
has been previously cleaned up. The needle is inserted into the dis- 
tended median basilic vein at the end of the elbow. For quantitative 
blood work, however, after the needle is inserted the bandage must be 
removed and circulation be allowed to return to normal before any 
blood is withdrawn, since the stasis has altered the concentration of 
the blood. 

Two forms of forceps are necessary (Fig. 98), the one with the 
crossed points which will hold one cover-glass, and the other the ordi- 
nary straight pinch forceps, with which the second cover-glass is to be 
handled. In the case of the first-mentioned forceps the two arms 
should come in contact for the whole length of the blade, and therefore 
hold one edge of the cover-glass solidly. The spring of the second 
pair should be as weak as possible, since when large numbers of cover- 
glasses are to be handled a stiff pair will weary the hand considerably. 
Beginners prefer to handle one cover-glass with their fingers, and 
426 



THE BLOOD 



427 



although this is advised by many good authorities, we insist that it 
shall not be done in this clinic, because the technique is certainly 
better if the fingers do not touch the cover-glasses. Also after the 
worker has become accustomed to the forceps, he can work more 
rapidly and accurately with the two than if he uses his fingers for one. 

The glass slides must be thoroughly cleaned for use in blood work. 
They have often a right and a wrong side, since they are cut from a 
flattened cylinder of glass ; in some boxes almost all are slightly con- 
cave on one side and convex on the other, since the flattening was not 
perfect. If the blood specimen is on the concave side the slide will 
rock on the stage of the microscope, hence making it impossible to 
keep a field in focus, while if the specimen is put on the convex side 
the slide will rest firmly on its two ends. 

The cover-glasses should be thin, No. i, or preferably No. o, and 
three-quarters of an inch square. Cover-glasses seven-eighths of an 
inch square are a little too large for blood work. In general only 
new cover-glasses shall be used. The reason for this is learned 
by bitter experience, because it is almost impossible to clean up a 
cover-glass so that small masses of detritus or haemoglobin will not 
remain on the glass, and the student will think it pigment or some 
other unusual thing in his next blood specimen. 

To clean this glassware considerable care is necessary. The tech- 
nique will depend on the state in which they are found when bought. 
We have received boxes of cover-glasses and slides which it was so 
difficult to clean that we discarded them. As a rule, however, there 
is little difficulty, and to wash them off in soap and water, then clean 
water, then in 95 per cent, alcohol is sufficient. If necessary, they 
should be soaked about twenty-four hours in concentrated hydro- 
chloric acid, then washed in water, then in 95 per cent, alcohol, then 
in ether. It is well to keep them either in 95 per cent, alcohol or, 
carefully wiped, in a glass dish. They should be handled only with 
forceps. For wiping them an old linen handkerchief is, we think, by 
far the best, since the repeated ironing has removed the most of the 
lint. A blood- worker should always have at hand a plentiful supply 
of clean glassware. 

In obtaining the drop of blood considerable care should be taken 
to select that portion of the body which promises the best results. 
To always prick the ear or always one finger is a decidedly foolish 
habit, since in some cases the one will serve much better than any 
other. A general rule, however, should always be observed, — to avoid 
any part which is cyanosed or cedematous. We have seen counts 
made on the two ears at the same time in which the leucocyte count 
varied by 100 per cent., and the same may be said of the two hands. 
The ear is usually the best part to prick, since it is always within reach, 



428 



CLINICAL DIAGNOSIS 



a nervous person cannot watch the worker, and it is relatively pain- 
less. In young children this last point is particularly true. And yet, 
if the lobe of the ear be small and thin it will be difficult to get a drop 
of blood from it. If the lobe of the ear is thick it is usually pricked 
on the flat side, it being stretched over the index-finger by the thumb 
and middle finger. In case, however, it is thin and considerable blood 
is necessary, it is well to prick on the edge and parallel to the surface. 
In cases of pernicious anaemia the ear usually offers much the best 
opportunity to get a good drop of blood. The Germans, as a rule, 
take the palmar surface of the ball of a finger of the left hand, and 
can usually get a good drop of blood. Our students, in studying 
their own blood, have learned to search on the anterior surface of the 
forearm for the pain points, and avoiding these, to always prick over 
a small superficial vein. In this way a good drop of blood is obtained 
easily and painlessly. In the case of very small children, the great 
toe or the heel is to be preferred. Each individual case should be 
studied, and before the prick is made the observer should decide what 
part of the body offers the best opportunities, whether the ear or the 
finger, the forearm or the foot, always remembering, however, that 
a congested or a cyanosed or an (edematous part is to be carefully 
avoided. It is particularly desirable, in case the patient is to be 
pricked at least twice a day, true of our pneumonia cases, to vary 
the parts selected so that they will not get sore. The patients will 
very soon tell us where they wish the drop of blood obtained. The 
needle need not be sterilized, but is first dipped into alcohol. The 
skin is washed off with alcohol and perfectly dried. 

The method of " stabbing" varies. Some prefer a short, quick, 
sharp blow ; others, slow pressure. Which method is to be recom- 
mended depends on the person using it. In general it may be said 
that in case considerable blood is desired a slow steady deep prick 
is better than a quick one. The patients much prefer a prick that is 
too hard rather than several which are not deep enough, and the 
unfortunate accident of going through the entire lobe is for the patient 
not so uncomfortable as the several light blows which beginners are 
apt to give. The part pricked should not be squeezed, nor should it 
be held in a position which will check its circulation, nor should it 
have been rubbed to increase circulation at that point, nor should by 
hard pressure the flow be aided, since by all of these methods the 
concentration of the blood may be slightly changed. The drops should 
well out. The first is wiped off, the second used. To encourage the 
flow a slight pressure probably does no harm, but to squeeze is not 
good technique. In case many drops are to be taken, the incision 
should be wiped occasionally with an alcohol sponge and then with 
a dry sponge, since this will keep the place bleeding better than a dry 



THE BLOOD 



429 



sponge alone. Always ask for a history of haemophilia, for the bleed- 
ing from even a small prick is in those cases difficult to check, and the 
very slightest prick will furnish enough or even too much blood. 

The Examination of the Fresh Blood. — The examination of the 
specimen of fresh blood is very important, and should be a routine 
procedure in every possible case. Yet many neglect it for the study 
of stained specimens, which should be considered of secondary value. 
In the majority of cases, of course it is the stained specimens which we 
study, since it is not always or often convenient for the practitioner 
to study fresh blood. We speak now of the relative value of the two 
examinations, other things being equal. Sometimes information of the 
highest value and of a very unexpected nature is learned from a fresh 
preparation ; more often hints are gained suggesting to the worker 
along what further lines to work. He will thus make examinations 
of which he might not have thought, and can save himself the time 
of some done as a matter of routine. Some things can be studied 
only in the fresh specimens, and more can be better studied there than 
in the stained. 

Technique. — The slide and cover-glass must be perfectly clean (see 
page 427). It is well that the slide be slightly warmed, perhaps by 
rubbing it rapidly with a cloth or holding it an instant near a flame, 
since the blood spreads much better on glass at about body tempera- 
ture than it does on a cold one. The size of the drop is a matter of 
considerable moment. One about as large as the head of the common 
small black-headed pin is right in most cases. The skin is punctured, 
the first drop wiped off, and the second or a later picked up from 
the ear by means of a cover-glass held in the pinch forceps, care 
being taken that the cover-glass does not itself touch the skin, and is 
then dropped at once onto a slide. The blood should spread evenly. 
Under no condition should the cover-glass be pressed down or tapped 
with the forceps to aid spreading, since this does not make a poor 
specimen good, and does too great mechanical injury to the corpuscles. 
After the drop has once touched the slide it is needless to say that 
the cover-glass, even though it projects over the edge, cannot be 
pushed into a better position. The student should always make sure 
that he puts the cover-glass on the convex side of the slide, since it is 
exasperating to have a rocking specimen under the microscope. The 
drop should be so small that when well spread the blood film hardly 
reaches the edge of the cover. The reason for this is that the observer 
needs the whole of a specimen, however small, under observation ; and 
since the distribution of cells varies at different parts of the slide, there 
is an advantage in a small drop. 

Red Blood-Cells. — In the well-made specimen the red corpuscles will 
all lie singly, flat on their sides, not overlapping nor in rouleaux. But 



430 



CLINICAL DIAGNOSIS 



in some cases it is important to know whether the tendency to rouleaux 
formation is increased or diminished, since in some diseases there is 
none, while in others it is so much increased that all the red blood- 
corpuscles are badly clumped. To test this a large drop of blood is 
used. 

The number of the red blood-cells may be guessed at with a cer- 
tain degree of accuracy by one who always uses approximately the 
same sized drop of blood. 

The shape of the red blood-cells is of considerable moment. In 
the circulation they may be cup-shaped, but in a well made specimen 
they flatten out on the glass, showing a biconcavity. When they do 
not flatten out well interesting pictures are gained; one looks, for 
instance, into the concavity of the cup the sides of which have con- 
tracted toward the centre and become almost parallel, enclosing an 
hour-glass-shaped orifice, the base of which is so thin that it seems 
absent. In the well-made specimen the cells lie perfectly flat and are 
quite round when alone, polygonal when in contact. Sooner or later 
near the edge of the specimen crenated cells are seen; that is, they 
become spherical and covered with small prickly points, giving the 
picture of a thorn-apple. These should never deceive, and yet they 
may in case a corpuscle presents but one of these projections, and 
that on its flat surface, in which case it is often mistaken for. a small 
ring form of the malarial parasite. By crenation, however, is meant 
not alone this artefact of prickle formation, but a change in the con- 
tour of the corpuscle; that is, instead of a round disk with an even, 
circular margin (unless, of course, the corpuscles are crowded one 
against the other), the margin is uneven and shrunken, as is seen for 
instance in quartan and sestivo-autumnal malaria. 

The presence of poikilocytes should at once attract attention. By 
these are meant corpuscles which are abnormal in the shape of the 
cell as a whole (not the fine irregularities of crenation). Poikilocytes 
may be due ( i ) to technique. If the cover-glass be pressed upon, a 
certain number of the corpuscles will fragment into small spherical 
masses and small elongated rods which resemble bacilli. The ease 
with which this fragmentation occurs depends to a great extent on the 
condition of the corpuscles. If, because of disease, they are " weak," 
a slight injury which would not affect a normal corpuscle will 
cause them to break up (Stengel). In case the cover-glass has 
been moved after the cells have spread, they will suffer consider- 
able distortion. (2) A specimen of fresh blood in a very warm, 
moist chamber, and especially if at 50 0 to 54 0 C, will present 
the most remarkable picture. The corpuscles lose their shape and 
show definite contractile movements ; some will elongate considerably 
and move around with a vermicular motion. We have known of a 



THE BLOOD 



431 



whole hospital staff studying with astonishment the gyrations of these 
overheated red blood-cells, sure that some new parasites had been 
discovered. More commonly the corpuscles under these conditions 
are seen to bud, and these buds to become detached and swim in the 
serum as microcytes. Sooner or later in such a specimen nearly all of 
the poikilocytes will fragment. (3) Age. When the specimen is made 
the corpuscles may be considered living cells, but in three or four hours 
death processes are visible; these appear much earlier in the blood 
of a diseased case. They are studied best in well-sealed specimens 
on a warm stage, and resemble those of the overheated specimen, 
except are less in degree. (4) But the poikilocytes which interest us 
most are cells which are misshapen when the specimen is first made, 
and which probably were so while in the circulation. A very few 
may be found in fresh normal blood. They occur in any severe 
anaemia, but especially in primary pernicious anaemia of even mild 
grade. Of the many forms, two were once supposed to be charac- 
teristic of this disease, those resembling a battledore, and the elongated 
or sausage forms. Poikilocytes certainly seem to have amoeboid mo- 
tion, at any rate, they are masses of contractile protoplasm. This 
is particularly seen in the small microcytes which can change their 
shape considerably and rapidly. (Plate I, 23-28; Fig. 93, k.) 

The elasticity of the cells certainly varies. The large pale cells 
in anaemia look flabby; poikilocytes may be cells which were round 
in the circulation but with diminished elasticity, hence when the smear 
is made lose their shape; in lead poisoning it is said to be increased. 

In the budding cells so often seen the projections may have the 
color of the normal cells or be paler or darker. They are attached by 
a longer or shorter pedicle, and often break free. Such buds which 
break loose and which have no haemoglobin are supposed by many to 
be illustrations of the formation of some blood-platelets. 

The size of the red blood-cells should be noted. Normally in 
the adult the average diameter is 7.5 microns. The student should 
carefully observe the variations in size; and try to determine which 
small cells are preformed and which the result of his technique. The 
size of the cells, so uniform in the adult (and yet a few dwarfs will 
be found), varies much in the normal infant blood. In certain dis- 
eases also the variation is considerable; in some, as in chlorosis, there 
is a quite uniform diminution; in other diseases, as pernicious anaemia, 
the majority of the cells will be larger than normal; in secondary 
anaemias the size varies, large, small, and normal sized cells being 
present, true also of pernicious anaemia, but to a less degree; in 
tertian malaria it is often the size of the cell which helps us to find 
the parasite, a large, swollen, pale cell attracting attention to the 
enclosed tertian form, while a small shrunken cell may point to a 



432 



CLINICAL DIAGNOSIS 



quartan or aestivo-autumnal, although in the case of the quartan the 
pigment and the protoplasm itself will probably first attract attention. 
The average size is said to be increased in jaundice, cholera, lead 
poisoning, and leukaemia; also in congenital heart disease and in 
cretinism. 

Color. — The color of the corpuscles, normally of a greenish- 
yellow, ma)* vary either in depth or in shade. Variations in depth of 
the color depend on the amount of haemoglobin, and the trained eye 
will even suspect the color index from the examination of the fresh 
blood. Often by focussing the biconcavity is seen in normal corpuscles, 
but is not very evident, and in many cells cannot even be imagined. 
In case of a " light-weight" corpuscle, however, it is much more 
prominent ; the corpuscles often appear to have no centre, and even 
a narrow ring may be all that is seen, the so-called " pessary forms." 
In other conditions the corpuscles seem to lack all biconcavity, and 
some may appear even biconvex, especially true of some microcytes. 

The change in color tone is of particular interest. This seems to 
be due to some chemical change of the haemoglobin. The corpuscles 
containing the quartan and especially the aestivo-autumnal parasites 
are beautiful illustrations of this, some cells which contain even a 
young ring-form appearing much darker than the other corpuscles 
and of a greenish " brassy" tone. A similar although less marked 
change in color is seen in microcytes and in cells fragmented by 
mechanical injury. The color of cells and fragments of cells seen in 
macrophages and phagocytes is so markedly changed, often so very 
green, that it is hard to believe it to be due to haemoglobin. 

In some diseases there is a quite uniform change in color. In 
chlorosis, for instance, nearly all of the cells are paler than normal ; 
in pernicious anaemia a large number will seem darker than normal. 
In other conditions there is more variation in the shade of the cor- 
puscle, as in secondary anaemia and in malaria. It is our custom 
each year to distribute to the class fresh specimens from several cases 
of chlorosis, primary anaemia, and secondary anaemia, and ask the 
students to decide from the appearance of the corpuscles from which 
condition the blood was obtained. They are required to make a 
fresh specimen of their own blood for comparison. Soon the students 
are able to express a pretty definite opinion concerning the nature of 
the case. 

Nucleated reds are sometimes very easy, but often very hard, to 
find in the fresh specimen, the nucleus being indistinct. To any one 
who has studied amphibian blood this is not at all surprising, since 
in that blood in which every corpuscle is nucleated one is often sur- 
prised at the small number of nuclei he really sees. An occasional 
normoblast is seen in normal blood, but it is a pure anomaly. 



THE BLOOD: RED CELLS 



433 



The degenerations of the red blood-cells are very important (Fig. 
93). These are necrobiotic changes, which appear sooner or later 
according to the intravascular condition of the blood, or the treatment 
it receives when or after the specimen is made. The " total" degenera- 
tions have already been described. More important than these are those 
partial degenerations which go under a variety of names, as vacuoli- 
zation, pseudo-vacuolization, pseudo-nucleation, etat cribriform, globu- 
lar decolorization, and more commonly Maragliano' s endoglobular 
degeneration, or, in short, " Maraglianos." These Maragliano endo- 
globular degenerations are seen in normal blood usually from thirty 
to seventy minutes after the specimen is made. Usually they are 
found in the centre, but may be near the periphery of the cell. A 
cell may contain one or several. At this point the corpuscle appears 
thinner and a vacuole-like area appears which seems free from haemo- 
globin (and the surrounding plasma stained). This area is usually 
round, although it may be elliptical, and increases toward the periphery 
until a mere rim of haemoglobin-containing protoplasm may be left. 
Although they resemble vacuoles, they are probably areas of coagu- 
lative necrosis. These degenerated masses certainly change their shape 
and their position within the cell ; they are extruded sometimes from the 
cell or remain when this goes to pieces. Whether their changes in 
shape are due to contractions of this degenerated protoplasm or to 
those of the surrounding normal protoplasm is a hard question, but 
the rapid motions that they make may lead the beginner to suspect 
that they are malarial parasites. It is not true amoeboid motion, since 
it is not through their change of shape that they change their position. 
The rapidity with which these appear in the specimen, other things 
being equal, depends on the intravascular condition of the corpuscles. 
Maragliano and Castellino have used the time of the appearance of 
these degenerated areas as a basis to group diseases and stages of 
disease, giving to it a certain prognostic value. They may have laid 
too great stress on these degenerations, but it is certain that in almost 
any severe disease, and especially in the primary anaemias, they appear 
much earlier than in normal blood. The best description of these 
degenerations is that given by Maragliano and Castellino. 3 These 
vacuole-like areas may be mistaken for nuclei and for malarial para- 
sites. The latter mistake, one may be sure from specimens sent to the 
clinical laboratories, has been responsible for several " unusual cases" 
of malaria which have been reported, in which it was claimed only 
hyalines were found. Although only the trained eye will recognize 
these, it may be said, in the first place, that their size differs from that 
of the parasite, beginning smaller and soon becoming larger ; that they 
grow more numerous the longer one searches for them, so that the 
1 Zeitschr. f. klin. Med., 1892, vol. xxi. 

28 



434 



CLINICAL DIAGNOSIS 



student is often surprised that he should have overlooked so many 
"parasites" at first, since he finds them so easily later; they occur, as 
a rule, in the centre of the cell, although this is not at all constant; they 
are round or oval in shape, and, what is most important, they look 
more like vacuoles with very sharp edges, although not much more so 
than does the ring form of the hyalines ; on changing the focus up or 
down this vacuole-like area enlarges or diminishes in size, while the 
parasite becomes more and less distinct; in general they are much 
easier to see than is the parasite; their movements may be similar to 
those of an amoeboid organism, and their periphery may show the 
same wavy motion, but true amoeboid motion is not present ; they 
change position and they change shape, but they do not accomplish the 
former by means of the latter. Beautiful " segmenters" may be seen 
(see Fig. 93, i). In Fig. 93 the attempt was made to show these 
differences (contrast a, f, and 0 with /). In fixed specimens they show 
a granular structure and will take a basic stain, but have no red chro- 
matin mass. 

Maragliano considers that many so-called nucleated reds are really 
nothing but these degenerated cells; but the differences in size, the 
changes in appearance of these on changing the focus, and the distinct 
chromatin net- work of the nucleus should not allow this error. 

Various other areas deserve particular notice; for instance the 
oval or ring forms, which are of the shape of a hyaline malaria ring 
with a circular refractive centre ; these sometimes have a definite cres- 
cent shape, and are famous since once described as the parasite of 
measles, and more recently as that of spotted fever (see Anderson's 
figures). What these areas are is not clear; they change shape in a 
peculiar way; they do not increase in number or grow larger on 
standing; they occur in the greatest variety of conditions, but espe- 
cially in measles (see Fig. 93, b). • 

In other cells are rod-like areas resembling bacilli, c. These 
" bacilli" may keep up a constant vibratory motion, moving practically 
through the whole substance of the cell, and hence the mistake some- 
times made of suggesting cultures to isolate this organism is not to be 
wondered at. We remember one physician who was confident that 
these were typhoid bacilli within the cells. Others speak of them as 
" splits" in the cell. 

Another common degeneration presents the appearance of a small 
cell on top of a larger and paler one, since the latter presents a dark 
circular area, but focussing shows them in the same plane (see Fig. 93, 
e, A, g). As a rule, this is an illustration of Ehrlich's hsemoglobin- 
aemic degeneration, areas of condensed protoplasm, haemoglobin sepa- 
rated from stroma; although superimposed cells do occur. Another 
example of this degeneration is in aestivo-autumnal malaria; cells are 



b c 



f 



m 



Fig. 93. — Fresh blood, a, cells with Maragliano's endoglobular degenerations ; b, cell containing a 
navicular body, from a case of measles ; c, the bacillus-like degeneration ; d , a Maragliano degeneration 
in process of extrusion; e, a form of "haemoglobin degeneration" giving a dark area; f, like a; g, 
like e; h, a degeneration like e but almost free from cell; i, a pseudo " segmenting parasite 1 ' ; k, 
an "amoeboid" microcyte ; /, aestivo-autumnal hyaline malarial parasites; m, a full-grown aestivo- 
autumnal parasite, and, n, a segmenter, both found in the peripheral blood; o, same as /; p, macro- 
phage from a case of pernicious malaria filled with malaria parasites. X 900. 



THE BLOOD: BED CELLS 



435 



seen in which the haemoglobin seems to be gathered in a mass around 
the parasite (see Plate V, o). This is also seen in nucleated red cells 
which have the appearance of a microblast lying on a macrocyte. It is 
often best seen in stained specimens. Engel emphasizes this appear- 
ance in the embryo of the mouse. He thinks it indicates that the proto- 
plasm clusters around the nucleus and separates as a small cell, leaving 
a large non-nucleated macrocyte, on the surface of which may some- 
times be seen traces, irregularities, of the spot which the cell left. But 
Engel expressly states that this method of cell-formation does not 
occur in the latter half of pregnancy nor after birth. (The view that 
this nucleus with protoplasm forms a lymphocyte may be merely men- 
tioned.) This degeneration may explain some of the " acidophilic 
granules" of the red cells which have been described. This degenera- 
tion is best seen in certain cases of pernicious anaemia. 

The granules studied by Vaughan 2 are to be observed in the fresh 
blood. The skin of the finger is well cleaned with alcohol and ether, 
and on it is placed a drop of Unna's polychrome methylene blue. The 
skin is pricked through this drop, hence the blood comes in contact 
first with the stain. A drop of the blood thus mixed with stain is 
transferred to a slide and covered at once with a cover-glass. In a 
few minutes a few cells are seen to contain granules staining violet. 
These granules are coarse or fine, sometimes in a line across the 
cell, sometimes connected by a filament. Their occurrence is remark- 
ably constant; in normal adult blood they are present in 0.5 to 1.8 
per cent, of the red cells; and in almost exactly this percentage of 
cells in a great variety of diseases with little influence on the blood; 
in the blood of new-born, in 1 to 7 per cent, of the cells ; in that of a 
foetus, two and a quarter inches long, in 24 per cent. ; in anaemias 
they are increased, in the primary pernicious occurring in even 18.8 
per cent. ; in general their number is parallel to that of the nucleated 
red cells. Vaughan gives good reasons for thinking that these 
are remains of the nucleus ; they are not artefacts, and occur especially 
in normal-looking cells, in the position of the nucleus, and in con- 
ditions in which nucleated reds occur. He suggests them as a more 
delicate sign of anaemia than nucleated reds, but of the same sig- 
nificance. 

Leucocytes. — The presence of a leucocytosis and its character will 
often be suggested by the fresh examination. The most of the surface 
of the specimen should be examined before forming a definite opinion 
of their number, since the distribution of these cells varies somewhat. 
Especially is this true of the so-called " stroked" specimens made by 
drawing the drop along the slide by another slide, a spreader, or a piece 
of paper. 

'Jour, of Med. Research, 1903. 



436 



CLINICAL DIAGNOSIS 



The leucocytes will be found as colorless, nucleated, amoeboid or 
' immobile cells, which do not float in the current. 

Lymphocytes. — These are in size equal to, larger, or smaller than 
a red blood-cell; the nucleus is relatively large, round as a rule 
although sometimes deeply notched, and central in position; the pro- 
toplasm is scanty, sometimes hardly seen, in other cases presenting a 
ragged edge around the nucleus, and may appear somewhat granular ; 
on the cold glass these cells of normal blood are not seen to move. 
Normally they make up from 22 to 25 per cent, of the leucocytes. 
On a warm stage those in lymphatic leukaemia especially are said to 
be amoeboid. 

Large Mononuclears. — These when typical are two or three 
times the size of a red blood-cell. The nucleus is often round, but 
more often oval in shape and eccentric in position. The protoplasm 
is very abundant and is clear. Although these cells appear non- 
amoeboid, yet it is interesting that in malaria they are the dominant 
phagocytes. They are about 1 per cent, of the total number. 

The " transitional cells" of Ehrlich seem to be old forms of 
the large mononuclears. They are the largest of all cells. The 
nucleus is pale and often deeply notched, giving it the so-called 
" saddle-bag" or the wallet-shape. The protoplasm is abundant. In some 
cells may be seen a few granules in the proximity of the nucleus. These 
constitute from 1 to 3 per cent, of the leucocytes. 

Polymorphonuclear Cells. — The finely granular cells of Max 
Schultze. constitute from 70 to 72 per cent, of the total number. They 
are from 10 to 15 microns in diameter, the size depending chiefly upon 
the extent to which the spherical cell is flattened out against the glass ; 
the protoplasm is clear and filled with fine granules of a dust-like 
character; the nucleus has the shape either of a bent rod, a skein 
of fibres, or, as a rule, there seem to be several masses of chromatin 
matter, hence the old name polynuclear cells. These when they 
leave the blood-vessels are the ordinary pus-cell and are the greatest 
phagocytes of the body. 

The coarsely granular cells of Max Schultze (eosinophiles) are 
usually a trifle smaller than the preceding. The nucleus is usually 
more regular, but this feature is not constant ; the protoplasm is 
filled with coarse, blackish, very refractive granules of quite uniform 
size and shape, being round or slightly oval and about 1 micron in 
diameter. These are the most amoeboid cells, of the blood, and make 
up from 2 to 4 per cent, of the leucocyte count. 

The Mastzellen in the fresh specimen resemble the finely granular 
cells. They cannot with any certainty be recognized, and yet will 
often be suspected. The granules are more irregular in size, some 
quite as large as of the coarsely granular cells, and do not fill the pro- 



THE BLOOD: LEUCOCYTES 



437 



toplasm quite so completely ; the nucleus is often trilobed. These 
cells are present in the normal blood to the extent of from 0.5 to 1 
per cent, of the total number. 

In various blood specimens the size of the leucocytes will seem to 
vary considerably. This depends upon the thinness of the smear, 
and hence the extent to which the leucocytes have flattened out. In 
the thick parts of the smear they will appear small, since spherical; 
in the thinner parts large, since flat. 

Pigmented leucocytes containing blood pigment are best studied 
in the fresh or air-dried specimens. This pigment may be melanin, 
blackish or brownish granules in which no iron can be demon- 
strated, formed within the malarial parasite, and when set free picked 
up by the leucocytes. These are very important in the diagnosis of 
malaria. Similar granules are seen in the leucocytes in cases of 
melanosarcoma and then indicate a generalization of the tumor. 

Hemosiderin pigment occurs rarely in the leucocytes in cases with 
rapid blood destruction as ochre granules. The iron may be demon- 
strated by treating the smear first with 2 per cent, potassium ferro- 
cyanide, then with 0.5 per cent, hydrochloric acid. The specimen is 
mounted in glycerin. The granules become blue in color. 

Miiller's Blood-Dust. — Blutstaubchen, or Hsemokonien granules. 
Miiller called attention a short time ago to the presence in the normal 
blood of very fine granules which danced actively between the cor- 
puscles. Finding a large number of them in a case of Addison's 
disease he supposed they bore some relation to that malady, but later 
decided that they were present in all bloods, although in very varying 
amount. They are described as small round colorless granules, which 
vary considerably in size, some one micron in diameter, but for the 
most part very fine and dust-like. The larger ones resemble micro- 
cocci. They are best seen by gas-light. Their nature Miiller could 
not determine, but since they did not give the osmic acid test he said 
they were not fat, although they resembled it, and as they were not 
cleared by acetic acid he decided they were not of albuminous nature. 

They were further studied by Stokes and Wegefarth, 3 who de- 
cided that they were the extruded granules of leucocytes. The reason 
for this opinion is that they resemble these granules in size, in man 
being both coarse and fine. Good additional evidence is furnished by 
comparative anatomy, especially the horse and rabbit, which animals 
have peculiar granulations in the leucocytes and similar blood-dust 
granules; they can be seen to escape from the leucocytes if certain rea- 
gents are added to the blood ; and, lastly, the larger ones take an eosirt 
stain. In the stained specimen the free granules are easily seen. Their 
relation to immunity, which point particularly interested these writers, 
s Jchns Hopkins Hosp. Bull., December, 1897. 



438 



CLINICAL DIAGNOSIS 



does not concern us, but from the study of fresh and dried blood 
the origin they suggest seems very probable for a certain number at 
least of these granules. It is probably these which have been described 
as spores of certain parasites in the blood. 

The fat of the blood is evident in the fresh specimens as exceedingly 
fine dust-like granules which would escape observation if they were 

not carefully looked for. These 
granules form a perfect cloud in the 
plasma in cases of lipsemia. 

The platelets are seen either 
singly or in large masses, or as 
masses of granules in the periphery 
of which are vacuole-like areas con- 
taining a watery fluid, the so- 
called " granular masses of Max 
Schultze." To one point we would 
call especial attention. In the fresh 
blood specimen all platelets will 
stick to the glass or to the cor- 
puscles, and any floating fragment 
of protoplasm is certainly not a 
platelet, however much it may re- 
semble it. (See page 539-) 

The fresh specimens are the 
best in which to study the large 
macrophages, enclosing malarial 
parasites, red cells, and cells con- 
taining parasites in malaria, and 
very many red cells in typhoid 
fever. These cells are very poorly 
preserved in stained specimens. 
(See Fig. 93, p.) 

In pregnancy placental cells 
(syncytium) " are commonly 
found" (Veit) in the mother's 
blood, perhaps being swept off in 
the blood-current. 

The fibrin net-work should be 
looked for: The fibrin strands 
are often seen 
small masses of platelets. The amount is 
eases, as in pneumonia, acute articular rheumatism, et ol. 

Counting the Red Corpuscles. — The instrument to be recom- 
mended is the Thoma-Zeiss (see Fig. 94), which we have found uni- 




Fig. 94. —Blood-counter (Thoma-Zeiss). To the 
right is the ordinary form of pipette for red cells ; 
the other is a leucocyte pipette with improved mark- 
ings and point, D. The ruled counting chamber is 
shown on edge and face view. A, the slide; B, 
the ring ; D, the ruled table ■ and C, the " ditch ;" 
E, the cover-glass. 



radiating from 
very large in certain dis- 



THE BLOOD: COUNTING 



439 



formly good. In this clinic we have in constant use fifty blood- 
counters, and can say that the Zeiss goods never disappoint us. We 
have tried slightly cheaper makes, but have always been obliged to 
discard them. For blood-counting the best instrument is none too 
good. 

The blood-counter consists of a pipette for mixing the blood to 
a certain dilution, a counting chamber by means of which a layer of 
known depth and area is. obtained, and a special cover-glass to serve 
as the upper boundary of this layer. The pipette is a graduated capil- 
lary tube (Fig. 94, A) opening into a dilatation, B, at the opposite 
pole of which empties a second shorter glass tube, D, to which is 
attached a rubber tube with a mouth-piece. This pipette is so gradu- 
ated that the capacity of the reservoir to a line on the shorter tube, 
marked 101, is exactly one hundred times the capacity of the capillary 
tube from its point to a line marked i. As a rule, the unit on the 
long tube is divided into ten parts, an unnecessary provision. Much 
to be preferred are those pipettes which have on either side of the 0.5 
and the 1 marks, two smaller marks, each indicating 1/100 the length 
of the tube (see page 491). The end of the long tube should be 
obtuse, as D, of leucocyte pipette, since in the quick movements made 
it is easy to break this point. In the dilatation is a small glass ball, C, 
which aids much in mixing the blood with the diluting fluid. The 
pipette is to be cleaned by washing out first with water, then with 
alcohol, and then with ether. Air is then sucked through, not blown, 
until the bulb is visibly clean and on rolling the tube the glass ball 
rolls freely within it. 

The diluting fluids used are several in number. The one com- 
monly used is Toisson's, the composition of which is 

Water (distilled), 160 cc. ; 
Glycerin (neutral), 30 cc.; 
Sodium sulphate, 8 gms. ; 
Sodium chloride, 1 gm. ; 

Methyl violet, 0.025 gm., or just enough to give the desired tint. 

Hayem's fluid is preferred by some : 

Distilled water, 200 cc. ; 
Sodium chloride, 1 gm. ; 
Sodium sulphate, 5 gms. ; 
Mercuric chloride, 0.5 gm. 

Sodium chloride can be used in rather strong solution (3 per cent.) ; but it 
is probable that the physiological 0.6 per cent, solution will lake a certain number of 
corpuscles. 

These fluids must always be fresh and recently filtered, since yeasts certainly 
do grow in those not containing an antiseptic salt, and these yeasts repeatedly 
lead to error. 



440 



CLINICAL DIAGNOSIS 



The counting chamber consists of a heavy glass slide, A, on 
which is cemented a thick glass ring, B, the surface of which is beauti- 
fully polished. This ring surrounds a circular table of glass, D, the 
height of which is just o.i mm. less than that of the surrounding ring, 
and upon this is the ruled area. Between this glass table and the inner 
edge of the ring is a small ditch, C , to catch the drop which may run off 
from the table and prevent its running up between the ring and the 
cover-glass on the other side of the ditch. On the central glass table 
are ruled twenty-one parallel lines, 0.05 mm. apart. Crossing these 
at right angles is an exactly similar set of lines. The result of their 
intersection is a 1 mm. square, divided into 400 equal small squares 
(see Fig. 95). Through each fifth row of squares is ruled an extra 
line. This extra line is not a boundary, but merely aids the observer 
to keep his position in the ruled area. Indicated, not bounded, by these 
extra lines, the square millimetre is divided into sixteen units of 
twenty-five small squares each. 

In choosing a blood-counter the lines should be carefully studied, since cer- 
tain makers have put on the market very imperfectly ruled slides. They should 
first be examined dry, to make sure that the lines are complete, and then covered 
with a drop of water that their sharpness may be determined ; for we have 
seen lines which appear very distinct on a dry slide practically disappear when 
a drop of water covered them, since the distinctness of the line when covered 
with water depends not on its depth and width, but on the sharpness of the edges. 
If this little point is borne in mind, there will be much less dissatisfaction with 
blood-counters. 

Before use this counting cell should be well washed with water 
and carefully wiped, care being taken that no lint be left on the surface 
of the glass ring. Alcohol and ether should never be used, since the 
centre glass table is cemented to the slide and is easily loosened by 
these reagents. 

The cover-glass is a heavy one with planed surface, made par- 
ticularly for this use. Ordinary cover-glasses can never be used, for 
they are of uneven surface; they are also cut from a sheet of glass 
often not well flattened, and hence will not lie parallel to the surface 
of the glass table; and lastly, they are so thin that the capillarity of 
the drop will bend them down slightly. 

Diluting the Blood. — After the ear, for example, has been 
pricked and the blood flows freely, a large drop is allowed to collect, 
which it should do rapidly, and is drawn into the pipette to the mark 
0.5 or 1 according to the nature of the blood. For normal blood 
it should be drawn only to the point 0.5, in anaemic persons to the 
point 1 . Before drawing in the blood the instrument should be tested 
to make sure that there is no obstruction in the tube. The blood is 
rapidly drawn exactly to the line desired. This will require consider- 
able experience. If drawn too far the column may be shaken down 



THE BLOOD: COUNTING 



441 



somewhat by tapping against a towel or rubbing it against the end of 
the finger, but unless there is very little correction to be made the 
instrument would better be cleaned up again and the whole work 
started anew. For this reason we prefer those pipettes with the extra 
marks indicating i/ioo the length of the tube, since if the column 
does not reach exactly the mark desired, it can be drawn to one of 
the other marks and then the necessary correction made. For in- 
stance, if drawn two marks beyond the i the worker should proceed 
and then diminish his final result by 2 per cent. Considerable error 
arises if the length of the blood column is not just right. With the 
long form of pipette which we use the error of 1 mm. means an error 



1 








1 






















































































e 








































































































































4— 














































































































































































-t 


















































































































\ — 
















































































































































































































B 












































































b 


























































































1 



































































































































































































































































































Fig. 95.— The one square millimetre ruled area, much magnified, showing the units in common use. 

in our result of 2.2 per cent., and in the more common short model of 
pipette, one of 2.6 per cent. The mistake of 1 mm. should not be 
made, but it is very easy to make one of 0.5 mm., and this error of 
1.3 per cent, is too great to disregard. (For these figures it is supposed 
that a red blood-count with the blood drawn supposedly to the 0.5 
mark is being made.) After the column is at the right height the tip 
of the pipette is then cleaned, either on the finger or by wiping it on 
a towel, and the pipette plunged into a bottle of the diluting fluid. 
The diluting fluid is now drawn into the pipette, the tube being held 
vertically and rotated between the finger and thumb while the fluid 
enters. By this rotation the diluting fluid mixes at once with the 



442 



CLINICAL DIAGNOSIS 



blood as it enters, and hence a layer of pure blood does not rise on 
the surface of the fluid and pass into the small tube undiluted; also 
in this way can best be avoided the bubble of air which often clings 
to the inside of the bulb. The fluid is aspirated until the mixture 
reaches the mark 101. It is not so necessary to accurately reach 
this mark, since a difference of I mm. in the case of the instru- 
ment now before us would mean a negligible error of only 0.03 
per cent. The pipette is now withdrawn from the diluting fluid, the 
thumb placed over its point, and then the upper end closed by the 
first finger. The rubber tube may be removed or not as the worker 
desires. The pipette is then vigorously shaken for at least one 
minute. It is to be shaken in all axes except perhaps directly in the 
long axis of the tube, which would allow a small number of corpuscles 




Fig. 96.— A, Zappert ruling; B, Turk's ruling. 



to be shaken into the column of fluid in the capillary tube, which, of 
course, contains no blood. Then at once two or three drops are 
blown out in order to remove that column of fluid which has not 
entered into the mixture. It is well now to let the pipette rest for 
about ten minutes in order that the leucocytes may become stained by 
the methyl violet of the Toisson's fluid. When, however, the pipette 
is picked up again, the shaking should be repeated as vigorously as 
before. If the blood is not to be counted at once, the pipette may be 
sealed by stretching a rubber band over its ends. At the end of 
several days it may be shaken again after the fluid in the long capillary 
tube has been first blown out. 

Pilling the Cell. — After shaking again and blowing out two or 
three drops, a small drop, the size of which can be learned only by 
practice, is blown out upon the ruled table and then covered at once 



THE BLOOD: COUNTING 



443 



by the cover-glass. The drop should not be so large as to run down 
into the ditch at any point, and should be large enough to almost 
cover the glass table. A large drop which runs into the ditch or too 
small a drop which merely covers the ruled surface will in either case 
introduce a certain error. The cover-glass should be put in position 
at once. The best way to do this is, we think, to grasp it by two 
diagonal corners, to place a third corner against the slide with the 
edge of the glass ring as a fulcrum, and to hold it in that position 
by a finger of the other hand. It is thus held up away from the 
drop by the edge of the glass ring as a fulcrum. By now raising 
the finger the cover is rotated onto the drop rapidly, and also in such 
a way that no air-bubble is left, which so commonly occurs if the cover 
be merely dropped on. 

The next step is to determine whether between the cover-glass 
and the glass ring is any dust or dirt, which, of course, increases the 
thickness of the layer of diluted blood. This is done by holding the 
slide almost on a level with the face and toward a window, and in 
such a position that the light is totally reflected from the surface of 
the cover-glass. If the cover and slide are in good apposition, a 
beautiful band of colors should cover the surface of the glass ring, 
due to the phenomenon of interference of light so beautifully seen in 
superimposed layers of thin glass. Should these colors not be there 
the cover-glass may be touched by some instrument, but not by the 
point of a pencil which leaves a small amount of carbon on the glass. 
This may bring out the color bands, and if they remain the specimen 
is satisfactory. If, however, around the point of pressure appear the 
concentric Newton's rings, and these disappear when the pressure is 
removed, this slide should be cleaned up and another trial made. Cer- 
tain workers seem to think that it makes but little difference if this 
phenomenon of light interference is not present. We consider it a 
very important point in the technique. When not present it usually 
requires considerable pressure to bring out five concentric rings, and 
we know that at the fifth ring the space between the cover-glass 
and the table is 1.4 microns, which is the thickness of one corpuscle. 
Over the rest of the surface, therefore, this distance must be con- 
siderable. Another method of getting the necessary contact is to allow 
a drop of the fluid to run under the edge of the cover, and then squeeze 
with the fingers the cover hard down on the slide (note the Hayem 
method). Dr. Cabot says that some put four small drops of the fluid, 
one for each corner of the cover, on the slide before the cover is 
put on. 

This phenomenon of light interference is to many a great bugbear. 
It should not be so. We find it is very easy or very difficult to obtain. 
In the case of a well-made counting chamber it is so easy that one 



444 



CLINICAL DIAGNOSIS 



attempt usually is sufficient, and from the clean appearance of the 
slide before the cover is put on one can predict whether or not the 
bands will appear. We have bought, on the other hand, counting 
chambers with which the bands could almost never be obtained. In 
handling the glass slide it should be kept as horizontal as possible, 
since a slight tilting may allow the cover-glass to slide off. If the 
cover be sealed by the fluid this will not happen. The counting cham- 
ber should now be allowed to rest for from three to five minutes that 
the corpuscles may settle down onto the surface of the glass, and hence 
render much easier the counting than if considerable focussing is 
necessary in order to bring them all into sight. 

It will be seen that at certain points of the technique the move- 
ments must be very rapid, and it is no exaggeration to say that 
greater mistakes are sometimes made by too careful than by too quick 
work ; since in trying to avoid slight errors greater ones are committed. 
The points of greatest importance are, the rapid filling of the pipette, 
and the rapid dilution with the fluid ; if considerable time be spent 
doing this, on the slide later will be found groups of corpuscles not 
broken up by the shaking ; the shaking must be thorough, and the 
drop of blood blown onto the counting chamber must be blown out 
at once after the shaking, and from the fluid in the interior of the 
bulb, not that from the capillary tube; lastly, the least possible time 
should elapse in putting the drop on the ruled table and covering it 
with the cover-glass. It is interesting to note that with the two instru- 
ments used by the French — the Hayem and the Malassey — are intro- 
duced two errors which we constantly try to avoid with the 
Thoma-Zeiss. Hayem recommends that an extra drop of the blood 
be allowed to run between the cover-glass and the table in order to 
seal the specimen against evaporation. Should a drop of the fluid in 
the case of the Thoma-Zeiss run from the ditch up between the glass 
ring and the slide, we would insist that the slide be cleaned up and 
the work done over again, yet others do not agree to this point, and 
think that thus is the light phenomenon more easily obtained. In the 
Malassey instrument is a mechanical contrivance for holding the cover- 
glass at a distance of o.i or 0.2 mm. as may be desired. 

The student should learn that it takes less time to clean up his 
counting chamber or his pipette and begin anew, than to count a lot 
of extra fields with the hope of counteracting some error which he is 
conscious of having made. If the worker has two slides the two can 
be used very conveniently, the one settling while the other is being 
counted. 

The next point is of great importance. Before counting a single 
cell the whole of the surface covered by the blood, even to the edge 
of the table far away from the ruled area, should be carefully examined 



THE BLOOD: COUNTING 



445 



with the low power, to make sure that the distribution of cells is even. 
If this is not the case, no matter how even it may appear over the 
ruled area, the slide should be cleaned up and another preparation 
made. , 

Counting the Cells. — The power to be used in the case of the Leitz 
microscope is, for beginners, the 6 objective and the No. I ocular. 
The cover-glass is usually too thick to allow of the use of a No. Ill 
ocular. Later on the student may be able to use a 3 objective and a 
No. Ill ocular. A mechanical stage is often of use, and yet it is 
better to train the fingers to do that work. 

The unit of the ruled surface (see Fig. 95) to be used is a matter 
of individual preference. Cabot recommends a unit of thirty-six small 
squares, D; that is, a unit the four sides of which are rows of squares 
through each of which passes one of the extra lines. Simon prefers a 
unit of the sixteen squares, B, through none of which the extra line 
passes. Sahli recommends a unit of four squares, A, four of which 
units make up the unit recommended by Simon. We prefer a unit 
of twenty-five squares, C, on two sides of which are rows with the 
extra line. The reason we prefer this is that it is to this unit that 
the slide is ruled, and the calculation of the corpuscles is easier than 
with any of the others, with the exception of the Sahli, and also that 
there is no danger, in case we count several units on one slide, of 
counting any corpuscles twice, as in the case of the unit recommended 
by Dr. Cabot. We count usually the four corner units, of twenty-five 
small squares each, of one slide, and then clean up and in a new drop 
count the same. In this way we have counted the cells over one-half 
of a square millimetre. The other workers recommend a much larger 
number than this and all state that it were better to count four 
hundred small squares. In counting, cells which touch the upper and 
the left-hand lines are included in the unit, while cells which touch in 
any way the right-hand or the lower boundary lines are to be dis- 
regarded, even though all but an edge lies inside or outside the square. 
Since counting is usually made downward and to the right, there is 
less danger of counting the same cell twice. If the cell is exactly in 
the corner it will be necessary to remember whether that particular 
one has been counted once or not. The beginner should pay no 
attention to leucocytes, counting them as if they were red blood-cells. 
The reason for this is that in normal blood in eight units the prob- 
ability is that but two leucocytes will be seen, an error of but 0.08 
per cent., which is, of course, negligible. It is easily seen that a very 
v high leucocytosis will introduce enough of an error to make it pay to 
strain the eyes to tell which are leucocytes and which are not, for 
although the methyl violet will stain the leucocytes fairly well, it will 
also stain a deep violet a certain number of red blood-cells, and for 



446 



CLINICAL DIAGNOSIS 



beginners at least it is difficult to tell in many cases the nature of 
the cell. Hence it is better, in leukaemia for instance, to count all 
leucocytes with the reds, then the leucocytes with acetic acid, and the 
difference will be the red cells. 

If the diluting fluid used be fresh or recently filtered everything 
seen may be counted as a cell. If spores are present they will appear 
like small mononuclears, and ridiculous counts due to this fact are 
sometimes reported. Many of the corpuscles will appear distorted, 
and in some anaemias very small cells are easily overlooked. They 
should all, however, be counted, since if the technique is good and 
the fluids clean only blood-cells will be seen. The high color index 
of pernicious anaemia has perhaps with reason been attributed to the 
fact that microcytes are overlooked. 

The students will thus count eight unit squares each of twenty-five 
small squares, and the sum of these cells will be the number over 
y 2 sq. mm. This in normal blood will be about 1250 cells. This 
multiplied by 2 gives the number of cells in 1 sq. mm. of a layer of 
blood 0.1 mm. thick; this multiplied by 10 will give the number of 
cells in a cubic millimetre of the diluted blood, and this multiplied by 
200 (providing the blood was drawn to the 0.5 point), the number 
of cells in a cubic millimetre of the undiluted blood, the desired figure. 
In case, however, that any other units are used it takes longer to 
calculate the count, except in the case of the Sahli unit, which is easy 
since his is 1/ 100 of the area of the square. 

The difference between the extremes of these eight figures, each 
the number of cells in a unit of twenty-five small squares, we do not 
allow in the work of beginners to be over twenty-five cells. The 
reason for this is as follows : .With good technique the distribution 
of the cells will be such that the extremes of these eight figures will 
easily fall within that limit. If they do not, it is easier to clean up 
and begin over, than by counting more units, trying to offset the error 
of poor distribution; if they do, then it is a waste of time to count 
any more units. Hence by good technique at the first considerable 
weary counting is avoided. If one's technique is so good that he 
can always conform to this rule, then later he can safely report a 
blood-count counting only four units or even only one. He may 
safely do this in his private practice. In the work of the clinic, how- 
ever, we do not accept such counts, although we are confident that 
they would be more accurate than the counts of one who has not by 
actual experiment learned his error and by practice corrected it, or of 
one who thinks it possible by counting sixteen units to offset known 
errors in technique. 



THE BLOOD: COUNTING 



447 



Our rule for training the third-year men is as follows : They are to use this 
method until they consider themselves fairly proficient. They then count the 
blood of one case, usually their own, daily at the same hour on each day until 
the difference between two successive days is not 200,000 cells and the difference 
between the highest and lowest of the eight units for each day is not over 
twenty-five cells (a good counter will often have a difference of only thirteen or 
fourteen cells). Two hundred thousand cells means that we permit a difference 
of 4 per cent. We choose this figure not because 4 per cent, represents the 
error in counting, but to make due allowance for daily variations which certainly 
occur, and because if the two counts vary by no more than this we are sure that 
the error due to counting alone is less than 2 per cent. Some students attain this 
quickly. We have known of students, however, who must repeat this for from 
twenty to thirty, even sixty, times before their work was satisfactory to themselves 
or to us. At the end of this time they are very certain to learn wherein lies 
the error in their technique. It is of interest that very often it is because they 
are too particular and take too much time in certain steps of their work. If the 
reader consides that it must be an awkward man who would take thirty days to 
attain this accuracy, we can only say that those alone who have tested their own 
accuracy know how inaccurate they can be, and that some of the least suc- 
cessful are the most surprised to find it out. Our students are seldom guilty of 
reporting " rises" or " falls" of 100,000 cells, nor do they ever report a count 
of 4,750,600. The student who is able to conform to this rule has confidence 
in his technique, a confidence which is usually earned by work. He has dis- 
covered his error if any has existed, and has learned to save himself considerable 
eye-strain, for we know in clinical microscopy of no task more wearisome than 
the counting of a large number of units. Blood-counting requires considerable 
practice. Even the good workers after a vacation of a few weeks find that it is 
necessary to make trials once or twice before they are ready again for accurate 
work. 

After the count is finished the slide should be washed with water 
only and the pipette rinsed first with water, then washed clean with 
alcohol two or three times, and then with ether twice. Air is then 
sucked through by mouth until the glass ball rolls easily. A suction- 
pump will save a great deal of trouble. The student must be careful 
to blow no saliva into the tube. If he draws in the alcohol before 
the blood is entirely removed, a precipitate will form. This may some- 
times be removed by nitric acid or by filling the pipette with pepsin- 
hydrochloric-acid mixture and leaving it in the thermostat overnight. 
In case a clot obstructs the bore of the pipette, it may be dislodged 
with a horse-hair; we do not allow a fine wire to be used, for this 
will easily crack off the end of the tube. 

As to the error inherent in blood-counting, we can only say the 
best workers have not considered it possible to count with less error 
than 2 per cent., and some are satisfied with 3 per cent. An error of 
3 per cent, would mean that two men counting with equal accuracy 
the same normal blood at the same time would get results which differ 
by about 1 50,000 cells. Good workers, however, will often come much 
closer than this, and we know of no better way to stimulate students 
to attain good technique than by insisting that a certain number of 
them, the more the better, shall each of them with a separate instru- 



448 



CLINICAL DIAGNOSIS 



ment count independently the same blood. We have seen this result 
in considerable extra practice. 

Other Methods of Blood-Counting.— The method of Hayem has 
been used considerably, particularly in France. Hay em's fluid (see 
page 439) is used as dilutant. 

Two ciiim. of blood are measured in a small capillary tube which much re- 
sembles that of a Gowers hsemoglobinometer, and blown into a small beaker, 
into which has already been measured by a larger pipette 500 cmm. of the Hayem 
fluid. It is impossible to wash out the large pipette, and since it is found that about 
6 cmm. remain in it, the blood is considered diluted 1 : 248. The blood is well 
mixed by means of a small glass rod. The counting cell consists of a glass 
chamber similar in some ways to that of the Thoma-Zeiss, but without any ruled 
table, the rulings being projected by a ruled chamber which fits into the substage 
of the microscope. The layer of diluted blood counted is a cube, each side of 
which is 0.2 mm., hence a volume of 0.008 cmm. He recommends that now a 
drop of the diluted blood be allowed to flow under the cover-glass, in order to 
seal the specimen. The number of cells found in this area multiplied by 248, 
and this by 125, will thus give the number of cells in 1 cmm. of undiluted blood. 

The Malassey instrument resembles the Thoma-Zeiss in many ways. A 
similar melangeur is used, and a slide with a ruled table, but the cover-glass is 
held by a mechanism which can be so adjusted that the layer of blood is either 
0.2 or 0.1 mm. thick. 

The Oliver Hasmocytometer. — This very ingenious and simple instrument 
is based on the principle that if blood be diluted by a fluid which preserves the 
corpuscles, and in a test-tube rectangular on cross-section and composed of a 
longitudinally striated glass, if through a suspension of opaque particles in such a 
glass tube a candle flame be observed, each striation in the glass will act as a 
lens projecting an image of the candle flame to the back wall of the tube. But 
this image can be formed only when the suspension is of a sufficient dilution to 
admit the almost unobstructed passage of the light rays. The blood is meas- 
ured in a small self-filling pipette, and is washed into the tube by means of 
Hayem's fluid from a medicine dropper the tip of which is covered by a small 
rubber tube. By shaking the test-tube covered by the thumb the suspension of 
corpuscles is made quite uniform, but the thumb should be slid off in such a 
way that the drop of blood clinging to the skin will be wiped off into the interior 
of the tube. The tube is then held between the thumb and the first finger in 
such a way that these form a frame, thus eliminating extraneous rays. The tube 
is held close to the eye, which looks through the long axis of its cross-section 
at a small candle ten feet distant in a dark room. The dilution and mixing are 
continued until at a certain point a bright horizontal line, which is a row of 
images of the candle flame, is seen across the test-tube. This line appears first 
at the edges of the tube. The proper dilution is obtained when these two 
lines from the sides just meet at the centre. The tube is graduated into one 
hundred divisions, the 100 point being that dilution found by experiment nec- 
essary to give the end reaction in a blood of 5,000,000 corpuscles per cubic 
millimetre. Hence each division corresponds to 50,000 cells. The end-reaction 
is so sharp that students trained to it insist they can detect a variation of 12,500 
cells. 

It should be distinctly remembered that Oliver invented this instrument as 
a more accurate means of counting the blood than are the Thoma-Zeiss and 
similar methods. He did not invent it as a short cut for approximate blood- 
counting. He distinctly stated that it was not to be used in diseases accompanied 
by a large variation in the size of the red blood-cells. We are sure from the 
quite extensive use that the instrument has had in this clinic that his claim in 
the case of normal blood is correct, and that slight physiological variations can 



THE BLOOD: BED CELLS 



449 



be detected, which would fall far within the limits of the accuracy of the 
Thoma-Zeiss instrument, and the instrument is to be heartily recommended for 
such work. We have found, however, that in the blood diseases, as he has 
warned, the error is so great that the instrument cannot be used. But the clin- 
ician cares nothing about physiological variations of normal blood, and finding 
that it is of no use in the blood diseases, and that in the primary anaemias there 
may be an error of over 2,000,000 cells per cubic millimetre, he discards it as use- 
less. We emphasize this because its use has been recommended as an approx- 
imate and easy method of counting the blood in all blood diseases, and would 
refer the reader to a paper by Baumgarten, 4 who emphasized the error arising 
from abnormal sizes of the corpuscles, and from the precipitate in the plasma. 

The Hematocrit. — This at first promised to save considerable 
time and eye-strain by giving a fairly accurate determination of the 
volume of the red blood-cells, that is, of the haemoglobin-containing 
protoplasm. The instrument is a modified centrifuge capable of very 
high speed. Some forms use a diluted blood; others the undiluted. 
In the second case in each arm of the centrifuge (see Fig. 97) is a 
small glass tube of rather large bore calibrated with 100 divisions. 
One of these glass tubes is inserted in a rubber tube with a mouth- 
piece and the blood drawn in until the tube is even more than full. 
This requires a very large drop. The finger, covered with vaseline, is 
then placed over the free end and then the rubber tube removed. The 
glass tube is inserted in the centrifuge, in the other arm of which is 
the empty tube to balance the machine, and at once as high a speed as 
possible obtained and maintained until the column of centrifugalized 
corpuscles does not decrease. Each division of the tube corresponds to 
approximately 100,000 cells. Multiplying the number of divisions by 
this will give an approximate blood-count and a fairly accurate esti- 
mation of the volume of the red blood-cells. This may be accurate in 
the case of normal blood, but as in the different anaemias in which 
alone blood counts are of great importance the corpuscles vary con- 
siderably not only in size, but probably in elasticity as well, it is not 
at all certain that they will always pack down to the same degree. 
At any rate, the instrument has not been very popular for blood- 
counting. As is so often the case, the method was used first con- 
siderably, then almost abandoned, and now is again coming into favor. 
Aspelin 5 centrifugalizes a blood diluted with Miiller's fluid in a special 
pipette. The blood need not be used at once, since this mixture will 
keep for some time. He reads the leucocytes at the same time. 

Capps 6 thinks the volume index important, and the numerator of 
this is determined with this instrument (the count is the denominator). 
He certainly has published some interesting results. We use the haema- 
tocrit to detect the presence of lipaemia, cholaemia, or haemoglobin- 

4 Johns Hopkins Hosp. Bull., July, 1902. 
5 Zeits. f. klin. Med., 1903, Bd. 49, S. 393. 
6 Jour, of Med. Research, 1903, vol. vi. 

29 



450 



CLINICAL DIAGNOSIS 



semia. In the latter case, however, it is only safe when the plasma is 
free to say that haemoglobinaemia is not present. Should the plasma 
be stained red one is not at all certain that this was so before the centri- 
fugalization, for the mechanical injury to the cells may have set 
free a certain amount of haemoglobin. The instrument requires very 
rapid work. It must be set up in close proximity to the bed. It makes 
a very loud and disagreeable noise, and hence is not a very satisfactory 
clinical instrument. To determine the volume of the red blood-cells 
the sedimentation by gravity in tubes to which a small amount of 
oxalic acid has been added to prevent coagulation is much preferred 
by some. 

In the use of the instrument the springs holding the glass tubes 
in place should be occasionally tested, and the cups in which the tube 
rests should have at their base a piece of soft rubber ; also the vase- 
lined end should always be the distal. If these precautions be observed, 
the blood should remain in the tubes, but very often the considerable 
centrifugal force forces the whole column out of the tube. 




Fig. 97.— Arm of haematocrit. 



A method which permits the specimens to be counted to be made permanent,, 
that the enumeration may be made at leisure, is given by Strong and Seligmann. 7 
The blood is diluted 1 : 100 for leucocyte counts, 1 : 20,000 for red counts, and then 
a quantity of known volume made into a dried and permanent mount. We 
judge it takes longer time than the ordinary method. Its results vary from I 
to 4 per cent, from those with the Zeiss. 

Leucocyte Counting. — For a leucocyte count the same mixture 
in which the red cells were counted may be used, especially if 
Toisson's fluid was the diluent employed. In this case after counting 
the red blood-cells, the leucocytes over the whole square millimetre are 
counted. The trained eye easily picks them out, more from the dif- 
ference in their refractivity than from any stain, since they are seen 
as bright cells when the focus is slightly raised. With the Thoma 
ruled slide the leucocytes in the whole millimetre field of eight separate 
drops should be counted. This requires about all the time at the 
disposal of the worker, and the number of cells counted is much too 
small, yet a fairly approximate result is obtained. It is much better 

7 Brit. Med. Jour., July 11, 1903. 



THE BLOOD: BED CELLS 



451 



to use a separate pipette for leucocyte counting, and a fluid which by 
laking the red blood-corpuscles leaves the leucocytes the only cells in 
the field. The best fluid is dilute acetic acid, from 0.3 to 1 per cent. 
A 0.3 per cent, solution is hardly strong enough, for the red blood- 
cells are not entirely laked, hence groups of shadows are seen which 
are very confusing. This does not occur if a stronger acetic acid is 
used. Our method is as follows : We give each student three bottles, 
one of glacial acetic acid, the second of distilled water, and this should 
be frequently renewed, and a third, a small bottle of about 30 cc. 
capacity with a wide neck and a label stating how many drops of the 
glacial acetic acid are to be added to the bottle filled with distilled 
water to the line of the neck to get a dilution just under 1 per cent. 
This mixture is made up fresh each day. A dilute acetic acid much 
older than this should never be used, for yeast-cells grow which if 
single will resemble mononuclear leucocytes. In case there are many 
and in chains they are at once recognized, but we know of too many 
instances in which a count slightly too large was reported because a 
few were present. The pipette used may be the same as that used in 
the red blood-count but the blood should be drawn to the 1 point, thus 
giving a dilution of 1 : 100. Better pipettes are those (see Fig. 94) 
which give a dilution of from 1 : 10 to 1 : 40, since the greater the 
number of leucocytes counted the smaller is the error. We do not 
agree that it is "not at all difficult" to use these big pipettes; they 
require more practice than the others. Their bore is so large that 
the blood easily drips out ; it is difficult to wash the blood entirely 
into the bulb by means of the acetic acid; and in shaking it it is 
easy to shake the leucocytes into the fluid filling the tube. To reduce 
these errors as much as possible, while the blood is drawn and while the 
acetic acid is aspirated into it, the pipette should be held almost hori- 
zontal ; a wide-mouthed bottle of acetic acid should therefore be used, 
which allows of an almost horizontal position of the pipette. The 
acetic acid should be sucked in rapidly, that the stream may wash the 
tube well. The pipette is shaken in all directions except in that of the 
long axis of the tube. In this case also the specimen should be first 
observed with the low power to make sure that the distribution is 
even. 

If the counting slide has the Thoma ruling, hence but 1 sq. mm. 
for use, this area from at least eight different drops should be counted. 
The Ewing, Zappert, or Turk rulings are to be preferred, since 9 
sq. mm. from each drop can be counted. This should be repeated with 
three different drops. At least one hundred leucocytes should be 
actually counted, and more if possible. If the acetic acid be of the 
proper strength and fresh, and the pipette clean, all objects seen may 
be counted. The number of cells found divided by the number of units 



452 



CLINICAL DIAGNOSIS 



counted and multiplied by 10, and this by the dilution, will give the 
number of leucocytes in i cmm. of undiluted blood. 

Beware of nucleated reds, since their nuclei are similar to small 
mononuclears. The hour of the count should always be stated, and 
also whether a short time before the count the patient had partaken 
of a heavy proteid meal. 

The error in leucocyte counting is usually at least 5 per cent. If 
a large number of leucocytes are counted, as was done by Reinert, the 
error will be about 3.5 per cent. We are sure that the error in the 
ordinary blood-count made by the busy ward man is nearer 10 per 
cent. We wish to emphasize this fact, for too often the clinical man 
who does not himself count blood draws from the counts made by his 
assistants conclusions concerning a rise or fall of leucocytes based on 
differences which fall within the limits of accuracy of the method as 
they apply it. We hear, for instance, of a rise of leucocytes from 10,000 
to 11,000 or from 20,000 to 22,000 per cubic centimetre and so on, 
and are confident that the blood is not nearly so much to blame for 
variations of this amount as was the worker. A careful man will 
by repeated controls of his counts make sure that his technique con- 
tains no error over 5 per cent. This can be done by filling at the 
same time several pipettes, which are then separately counted, or better 
by occasionally inviting another, in whose work he has confidence, 
to make a series of parallel counts with him. In control work the 
blood should be taken at the same time and from the same incision, 
for one can obtain curious results by taking his blood from different 
parts of the body if he does not observe due precaution to avoid the 
ear on which the patient has been lying or the hand which has been 
in a hanging position for some time. 

Blood Smears. — For satisfactory stained specimens the first neces- 
sity is to get good smears, thin, with the cells well spread and only 
few overlapping. The method we employ is the Ehrlich, using two 
cover-glasses. The cover-glasses, three-quarters of an inch square and 
of the thinnest glass and best quality, are thoroughly cleaned in alcohol 
and ether (see p. 427) and then dried. One cover-glass is held on one 
edge by the crossed-bladed forceps. The other cover-glass is placed in 
a convenient position to be quickly picked up by a pair of ordinary 
pinch forceps. A small drop of blood about the size of a small bead 
(about 1.5 mm. in diameter) is picked up on the last-mentioned cover- 
glass which is then at once dropped onto the other cover-glass. If these 
covers have been properly cleaned the blood will spread out rapidly 
from the weight of the cover-glass alone, and without the assist- 
ance of any pressure, which should be carefully avoided. Just as the 
spreading of the film is about to stop, but before it does, the two 
covers are pulled apart in a line parallel to their plane by a steady 



THE BLOOD: STAINING 



453 



but quick motion (see Fig. 98). After a little practice one will suc- 
ceed almost every time. Beginners find it much easier to handle the 
free cover-glass with their fingers. We do not approve of this, for 
the moisture on the finger certainly does affect the specimens to a 
slight degree, and after one has had considerable experience he can 
make one hundred or more smears, a number which must often be 
made for our class, in less time with than without the second pair of 
forceps. As soon as the covers are drawn apart they may be waved 
in the air until dry, not warmed over a flame. They then remain 
spread out on a sheet of paper for from fifteen to thirty minutes to 
become further dried, but must be watched, for flies work havoc with 
such smears, sucking up the haemoglobin and leaving large holes in 
the specimens. For some stains 
the smear is not allowed to become 
dry, but is dropped at once into the 
fixing fluid. If kept, they should 
be guarded from dust and moisture. 

Others prefer to make the blood 
specimens on slides, in which case 
a cover is dispensed with. A large 
drop is placed on a slide and the 
smear made by drawing it along the 
slide by the edge of another slide, 
or, better, by a spreader with a 
ground edge, or, better still by a 

, . r ^ 1 • • Fig. 98— Method of making cover-glass 

strip of paper, the ordinary cigar- preparations, 
ette-paper giving splendid results, 

while others prefer to use a needle which is drawn flat across the slide. 
Beautiful specimens may be obtained in this way. It has the advan- 
tage of dispensing with the use of cover-glasses entirely and of giving 
a much larger blood surface. On the other hand only a few smears 
can be made ; it takes more blood, and many slides cannot be handled 
as easily as the same number of covers. As a rule, they are not well 
spread. It is important to get uniform specimens with thin edges. The 
distribution of cells on a smear is never uniform. Leucocytes are 
found especially at the edges, and platelets at the point first touched 
by the blood. A proof of this is that several smears have been sent 
us as illustrations of extreme leucopenia. In one case it was claimed 
not a single leucocyte could be found, but plenty were by those who 
knew the tricks such specimens play. The distribution of cells when 
two cover-glasses are used is not the same on each ; it is also true that 
when the technique is slow many of the leucocytes are in a mass on the 
area first covered by the drop, which often gives the mistaken notion 
of an extreme leucocytosis. 





454 



CLINICAL DIAGNOSIS 



It is of the greatest importance to obtain good specimens. With 
the most careful technique some of the most interesting cells are 
nearly always ruined. We refer to the macrophages and to the very 
large mononuclear cells which can be found in sections of drops of 
blood hardened en masse, and in fresh specimens. 

The smears thus dried in the air may be kept some time. One 
obtains better results with Ehrlich's stain by heating after three or 
four days than on the first day, while in the case of the many methy- 
lene blue-eosin stains now in vogue it is much better to stain at once, 
even before they are air-dry. 

Fixing Methods. — The fixing method used will depend upon the 
stain which it is intended to employ. Among the various chemical 
methods are: 

( 1 ) Nikiforoff's, consisting of absolute alcohol and ether equal 
parts; the specimen is to be immersed for from a half to two hours. 
This method is particularly good for malarial specimens and for the 
degenerations of the red blood-cells. 

(2) Absolute alcohol for five minutes, or, if in a hurry, boil- 
ing absolute alcohol one minute. 

(3) Flemming's solution, particularly good for the study of the 
chromatin of nuclei, consists of chromic acid, 1 per cent., 15 parts; 
osmic acid, 2 per cent., 4 parts; glacial acetic acid, 1 part. The 
blood specimens, as soon as made and before they could possibly 
dry in the air, are plunged immediately into this fluid and left for 
ten minutes. They are then washed in running water for about ten 
minutes and dried. 

(4) Vapors of Formaldehyde. — The specimen is put under a 
bell- jar together with a few drops of formaldehyde, and is exposed 
thus to its fumes for about five minutes. 

(5) The Futcher-Lazear method employs 0.25 per cent, for- 
malin in 95 per cent, alcohol for one minute. To 10 cc. of 95 per 
cent, alcohol are added 4 to 5 drops of 10 per cent, formalin (i.e., the 
strong formalin of commerce, 40 per cent., diluted with three vol- 
umes of water). This is always made fresh. The specimen is left 
for one minute, then rinsed in running water, and dried on filter paper. 

(6) Heat. — This method, the most difficult to use well, is the 
only method which gives satisfactory results with the very important 
Ehrlich triple stain. The best apparatus is that originally introduced 
by Ehrlich, — a large triangular copper plate, not polished, with a 
gas-burner under the point. This is allowed 'to heat until at a con- 
stant temperature, and then the boiling point determined by dropping 
water at different distances from the flame until the point is reached 
where it just boils. The cover-glass is placed blood-side up on the 
copper plate inside of the boiling point, that is, toward the flame, 



THE BLOOD: STAINING 



455 



with its outer margin about three-quarters of an inch from the boiling 
point; that is, at a temperature of from no° to 115 0 . Another 
way is to use drops of toluol or xylol instead of water; the boiling 
point of these is the point sought. Very good specimens may be 
obtained in from an hour and a half to two hours. It is better to move 
the specimens up to this point gradually, and at the end let them cool 
slowly to avoid shrinking or splitting the cells by too rapid changes 
of temperature. The time necessary will depend on two things : first, 
on the age of the specimen, for in case the blood is heated on the day 
that the specimen is made two hours will be hardly long enough. 
That it is not well to heat on the day the specimen is made is shown 
by the fact that the trained eye can usually tell if that has been done, 
by certain undesirable qualities in the specimens. In case the speci- 
men is a week old an hour and a half is usually sufficient, and for 
very old specimens sometimes less than an hour. Second, on the disease 
which is to be studied. Normal blood requires the longest heating. 
Splenomyelogenous leukaemia specimens are ruined usually if left on 
the bar more than one hour, and a difference of fifteen minutes may 
be fatal to a pernicious anaemia specimen. (Our method is to place 
four cover-glasses at the same distance from the flame, removing the 
first in one hour and the others at intervals of about twenty minutes. 
One of these is quite certain to be good, and the rest are heated for 
this length of time.) Others place the blood specimen at the boiling 
point, but with the blood-side down, for about fifteen minutes. 

A thermostat is very convenient to use, but one must be sure 
that the thermometer measures the temperature of the plate upon 
which the cover-glasses rest, rather than of the air above it. Ehrlich 
recommends a temperature of 1 io° to 120 0 for from an hour and a half 
to two hours; Engel a temperature of 125 0 to 135 0 for that same 
time; while Cabot, 150 0 for ten minutes. If in any case this high 
temperature be used, the glasses are placed in the oven while cool, 
the temperature of which is then slowly raised to 150 0 , the flame 
then removed, and the oven allowed to cool slowly. 

Others prefer to simply run the cover-glass, but especially the 
slide, through the flame two or three times, in the same manner as 
smears of bacteria are fixed, and often get splendid specimens. The 
" Spheroidal point method" is often excellent. That point on the 
copper bar is determined at which the " spheroidal phenomenon" 
occurs ; that is where the drop rolls off without boiling. The tempera- 
ture here is 140 0 to 150 0 C. The smears are placed at this point face 
up for from thirty to one hundred and twenty seconds. 

Various ovens are sold which give a very constant temperature, 
since they are heated by fluids whose boiling point is the one desired. 



456 



CLINICAL DIAGNOSIS 



Among these may be mentioned the Viktor Meyer, and lately the 
Ehrlich ovens. In these ovens xylol or toluol is used. 

In the case of the Ehrlich stain the success in staining will depend 
on the heating; if the specimen appears over-stained it was under- 
heated; if unstained, it was overheated. The red blood-cells are a 
good index; they must show no fuchsin tint whatever, nor again a 
lemon-yellow. The amount of stain which the plasma will take also 
depends on the time heated ; there should be no halo around the cor- 
puscles, under-heating bringing out Deetjen's " cell membrane." 

Wood alcohol is, however, the fixative preferred by most since 
it can be mixed with the stain, hence the fixing requires no extra work. 

In the choice of a method the subject studied must be taken into 
consideration. For the granulations heat is the best method, since it 
allows the neutrophile granules to take the specific stain ; osmic acid 
2 per cent, at a temperature of 37°, the specimens before they are 
air-dried being exposed to these vapors; . or chromic acid 1 per cent., 
the specimen fixed for from two to ten seconds and then washed in 
distilled water at once for from two to ten seconds, may also be 
used. For the study of the nuclei, Flemming's fluid or the Nikiforoff 
method is best; for protoplasm, chromic acid, osmic acid, or alcohol 
and ether. 

Stains. — Stains have been classified by Ehrlich as acid, basic, and 
neutral. These words do not refer to their chemical reaction, but to 
the portion of the compound which does the staining. The classical 
illustration of this is the following: ammonium picrate is an acid 
stain, since it is a picric acid which gives the color ; rosanilin acetate 
is a basic stain, since it is the basic element which is efficient ; as an 
illustration of a neutral stain rosanilin picrate would serve, since both 
the basic and the acid parts would stain. As a matter of fact the 
neutral stains are all of them mixtures of one or more stains, and it 
is very hard to state just how the compound arises and what it is. 

Among the basic stains may be mentioned methyl green, methylene 
blue, fuchsin, methyl violet, Bismarck brown, and saffranin. 

Among the acid, eosin, aurantia, the salts of picric acid, indulin, 
acid fuchsin, orange G, and a long list of others. 

Neutral stains arise in mixtures of the above. For instance, of 
acid fuchsin and methyl green ; of methylene blue and eosin. 

Methods. — (1) Futcher and Lazear recommend a saturated 

SOLUTION OF THIONIN IN 50 PER CENT. ALCOHOL, to 20 CC. of which 

100 cc. of 2 per cent, carbolic acid are added. • This stain is allowed 
to stand for some time. The specimens fixed by the alcohol-formalin 
method (see p. 454) are stained in this for from ten to fifteen seconds. 
This was particularly valuable for malaria specimens, the hyalines 
showing as reddish-violet ring-like bodies. 



THE BLOOD: STAINING 



457 



(2) Eosin and methylene blue are often convenient to use. 
Eosin 0.5 per cent, in 70 per cent, alcohol is diluted one-half by water, 
the specimens stained for a few minutes, then washed and blotted. 
They are then covered for three-quarters of a minute with a saturated 
aqueous solution of methylene blue which has also been diluted one- 
half just before use. 

(3) Chenzinsky's stain: Methylene blue, sat. aq. sol., 40 cc. ; 
eosin, 0.5 per cent. sol. in 70 per cent, ale, 20 cc. ; distilled water, 
40 cc. The specimens fixed in absolute alcohol from five to thirty 
minutes are stained in the thermostat at 37 0 C. in the above stain for 
from three to six hours ; beautiful specimens result. 

(4) Hematoxylin Eosin. — This stain is not used nearly as 
much as it deserves, since there is no better way of bringing out the 
nuclei. Attention has been diverted so much lately to granulations 
that all else has been considerably neglected. 

Mayer's Solution. — Hematoxylin, 1 gm. ; alcohol, 100 cc. ; 
while cool, 50 gms. of alum are added, and then 1000 cc. of boiling 
distilled water. A few crystals of thymol are then added, the whole 
cooled, and filtered. It is to be kept in the dark. Only experience 
will tell how long the specimens are to be stained. They are after- 
wards washed rapidly in water. The nuclei will alone take the color. 
Eosin, 0.5 per cent, aqueous solution, may then be added until the 
red blood-cells are just rose-red. The specimen is then washed in 
water, dried, and mounted. The protoplasm and the nuclei are beauti- 
fully stained, but the granules not so well. 

Ehrlich's mixture: Eosin (cryst), 0.5 gm. ; hematoxylin, 2 
gms.; absolute alcohol, distilled water, glycerin, aa 100 gms.; glacial 
acetic acid, 10 gms. ; alum, in excess. This is allowed to stand for 
several weeks. The specimens are stained for from one-half to two 
hours. 

(5) Ehrlich's Triple Stain. — The words Ehrlich's " triacid" 
and Ehrlich's " triple" stain are often wrongly used as synonyms. 
The triacid stain was a mixture of indulin, nigrosin, and aurantia, 
equal parts of the saturated solutions. This stain was to bring out 
the eosinophile granules. It is hard to make up, and is now very little 
used. By the word " triacid" is usually meant the triple stain next to 
be mentioned. 

Ehrlich's triple stain is a mixture of the saturated aqueous solu- 
tions of methyl green 66, acid fuchsin, and orange G. (Grubler's stains 
are usually used.) These solutions are allowed to stand at least one 
week, and if longer give still better results. 

Since only about one mixture in ten is a success, it is better to 
make it up in small quantities. 

In a beaker are mixed: Saturated solution of orange G, 13 to 14 



458 



CLINICAL DIAGNOSIS 



cc. ; saturated solution of acid f uchsin, 6 to 7 cc. ; distilled water 
and alcohol, of each, 15 cc. ; saturated solution of methyl green 6 b, 
added drop by drop, stirring all the time, 12.5 cc. ; alcohol, 10 cc. ; 
glycerin, 10 cc. 

If the mixture is a success the stain has a russet-brown color, not 
a deep red. In case it was one of the nine failures, one may try a 
little doctoring with more orange G, or more methyl green, but this 
seldom improves matters, and those with much experience throw it 
away and start over. 

This stain seems to improve for a time on standing, but when 
old certainly spoils. It should never be shaken, and should not be 
filtered. The drops to be used are removed on the glass rod from as 
near the centre of the bottle as possible. The specimen is covered 
with this stain for from three to twenty minutes. It is very difficult 
to overstain, films presenting this appearance are usually underheated. 
The specimen is then washed in distilled water, quickly blotted, and 
mounted in balsam. It may be quickly washed in absolute alcohol, 
which brings out the granules more clearly but makes the nuclei paler. 
In a successful specimen the red blood-cells will be of a buff color 
without the slightest shade of red; the nuclei of the leucocytes will 
be of a dark green, of the normoblasts almost black; the neutrophile 
granules will take a lilac stain, the eosinophile granules, a crimson. 
This is the only stain which gives a specific color to the neutrophile 
granules, and it is for this purpose that it was introduced. It is 
inferior to other stains, both for the protoplasm and for nuclei, and 
does not in the least stain the Mastzell granulation. While the neu- 
trophile granulation was considered very important, this stain was 
uniformly used, but to get a good idea of the blood as a whole its use 
is limited, and other specimens should be stained by some other 
methods, preferably hematoxylin and eosin or methylene blue and 
eosin, or by all three, that the other points be not neglected. 

Certain bloods will be found which take the stain poorly; others 
well. In certain diseases, particularly lymphatic leukaemia, it is almost 
impossible to get a good specimen with this stain, since the basic 
element is so markedly lacking. 

There seem to be individual peculiarities in bloods. Our students are re- 
quired to stain their own blood until satisfactory smears are obtained, in order 
that they may learn how to judge of specimens. Some students will succeed the 
first time; others have made even 100 to 150 specimens from their blood without 
getting a satisfactory stain. Other students trying these same bloods will have 
no better success. Certain peculiarities of the staining qualities of cells will 
be so marked that it is possible sometimes to recognize whose blood (of a limited 
number of students) is under the microscope, provided the observer has already 
studied that blood. During the past year, in following the work of ninety students, 
we were more than ever convinced as to this point. The staining qualities of bloods 
depend on other factors quite as much as on the fixing and staining technique 



THE BLOOD: STAINING 



459 



and fluids used. Why several students cannot get a well-stained specimen of one 
blood and will of another must depend on the bloods. We have been unable 
as yet to trace any relation to time of day, diet, etc. 

The polychrome methylene blue-eosin stains are at present 
the favorites, since they are easy to use, contain the fixative, and 
give fairly satisfactory results. In the case of malaria they are the 
best stains to use ; since it is only they which bring out the chromatin 
of the parasite. For blood smears they are satisfactory; the nuclei 
stain very well, also the Mastzell granulation, and the protoplasm. 
The eosinophile granulation can be easily recognized, and the neutro- 
phil granules stain perhaps as well as is necessary, and may be recog- 
nized from their fine size and purplish tint. However, if one is study- 
ing granulations, he will not use this stain alone, nor, indeed, any stain 
containing methylene blue, which is very tricky. At least sixteen dif- 
ferent methods 8 of making this stain have been reported, all of them 
modifications of the original Romanowski. The method which we use 
is that described by Hastings in the Johns Hopkins Hospital Bulletin, 
1905, since it is one of the easiest to make up and so seldom fails. 9 

Hastings' Stain. — The dry stains necessary are eosin, soluble 
in water, yellow (Griibler) ; and methylene blue (Ehrlich's rectif.) 
(Griibler). 

Solution A = eosin 1 per cent, aqueous. 
Solution B = alkaline methylene blue 1 per cent, aqueous. 
Solution C = methylene blue 1 per cent, aqueous. 
Solution A may be kept ready-made; solutions B and C must 
be made fresh. 

To prepare B use warm 1 per cent, solution of dry powdered 
sodium carbonate. Add to it 1 per cent, of methylene blue powder 
and heat over a water-bath for fifteen minutes. Add 30 cc. of water 
for each 100 cc. of original fluid, and heat again fifteen minutes. 
Then pour off the solution from the residue, divide into two equal 
parts, and to one part add enough 12.5 per cent, acetic acid to faint 
acid reaction. This is best determined by placing a drop on blue 
litmus paper and taking as the end reaction the point at which the 
margin of the drop after absorption in the paper shows a faint pink. 
Then add the remaining unneutralized portion to this. 

To mix the stain use distilled water, 1000 cc. ; solution A, 100 
cc. ; solution B, 200 cc. ; solution C, 70 to 80 cc. In adding solu- 
tion C, put in 70 cc. at once, stir well, and if no precipitate is present 
add a cubic centimetre at a time until one appears. After the pre- 
cipitate appears the stain is allowed to stand for half an hour, and 
then filtered through one filter. Forced filtration is usually necessary. 

"Baumgarten, American Med., 1904, vol. vii. p. 14. 

9 See, also, Wright's Method, Jour. Med. Research, 1902, vol. ii. p. 138. 



400 



CLINICAL DIAGNOSIS 



The dry residue is removed from the paper, powdered up, and may- 
be kept in this form or dissolved in Merck's pure methyl alcohol. 
Seven- to nine-tenths of a gram of dry stain is usually obtained. 
Three-tenths of a gram dissolved in 100 cc. of alcohol gives the stain- 
ing solution. In dissolving the stain it must be rubbed up with the 
alcohol in a mortar and pestle, as it is with difficulty soluble. 

If more than nine-tenths of a gram of dry powder is obtained the 
resulting stain is useless. For each new lot of stain made up one 
must determine the relative proportions of stain and water to be used 
in staining and the relative lengths of time in which to let the pure 
and diluted stain act. Usually 2 drops of stain for one minute on the 
smear and then with 4 drops of water to it for four minutes gives the 
best result. For uniformity in the size of drops a dropper should be 
used. The two drops of undiluted stain for one minute fixes the speci- 
men, which, after the addition of the water, receives its differential 
stain. 



All of these methylene blue-eosin stains require experiment, since 
different mixtures by the same method require slight variations in 
their use, learned only by trial. The reason for accuracy of dilution 
is to prevent a fine black precipitate, which detracts much from the 
beauty of the specimen. This precipitate may be removed by slight 
decolorization in 95 per cent, alcohol. If too much decolorized, it is 
the red chromatin of the malarial parasite which suffers the first. Only 
the purest methyl alcohol should be used; use distilled water to wash 
the specimen, since tap-water sometimes ruins it. 

Jenner's stain is excellent for ordinary blood work, but lacks the 
red chromatin-staining element. It has this disadvantage, but no 
advantages over the somewhat similar polychrome methylene blue- 
eosin mixtures, which are no harder to make up. 



For basophile granules the methylene blue stains, carbol thionin, 
or dahlia may be used. 

Another carbol thionin mixture is thionin, 0.3 gm. ; absolute alco- 
hol, 10 cc. ; carbolic acid, 1 per cent., 100 cc. The fixed smear is 
stained two minutes, washed in water, and 'dried. 

Ehrlich's dahlia stain consists of distilled water, 100 cc. ; saturated 
alcoholic (absolute) dahlia solution, 50 cc. ; then, on clearing, 10 to 
12.5 cc. of glacial acetic acid. The specimens (heated or fixed by 
alcohol, etc.) are stained for from five to ten minutes. 



(1) Gravimetric Method, (a) Pycnometer. — This method is 
certainly the most accurate, but requires considerable blood (at least 
5 cc. for an accurate estimation) and a very accurate chemical balance. 




SPECIFIC GRAVITY OF BLOOD 



THE BLOOD: SPECIFIC GEAYITY 



461 



(b) Schmalz Tubes. — This method is less accurate than the 
above, of which it is a modification, using tubes which hold much 
less blood, about o. i cc. These tubes are about 12 cm. long and 
1.5 mm. wide, slightly constricted at the ends to prevent loss of blood. 
A tube is well dried and weighed on a chemical balance which is 
accurate to at least 0.1 mg. It is then filled with distilled water and 
weighed, well cleaned and dried, filled with blood, and again weighed. 
If c equals the weight of the tube, c' , the weight of the tube filled 

c" c 

with water, c" the weight of the tube filled with blood, then — ; — 

c' — c 

= sp. gr. This method, while accurate, requires considerable skill. 

(2) Araeometrical Methods. — In these are used fluids of dif- 
ferent specific gravities into which a drop of blood is introduced. If 
the drop rises, it means that the specific gravity of the fluid is too 
high. If it sinks, too low. The Roy method uses a series of bottles 
with fluids of various specific gravities, into samples of which drops 
of blood are introduced until one is found in which the drop neither 
rises nor sinks. 

In the Hammerschlag method 10 a mixture of benzol and chloro- 
form is used, and this mixture modified until it is of the right specific 
gravity. A glass cylinder perfectly clean and dry (or else the drop 
of blood will cling to the side of the glass) is filled with a mixture of 
about 1058 specific gravity. The drop of blood is then introduced, 
best through a capillary tube bent at the end at right angles so that 
the drop may be blown in without giving to it an up or down motion. 
If the drop rises, benzol is added; if it sinks, chloroform. After each 
addition the fluid must be well stirred. The mixture evaporates, hence 
its specific gravity changes rapidly, and since there is an interchange 
between the blood and the fluid, it is important to work very rapidly, 
to confirm the result by a fresh drop of blood, and to test the 
specific gravity of the mixture before any evaporation has occurred. 
The drop of blood may be removed by filtering through linen before 
the specific gravity is tested. Care must be taken that no bubble of 
air sticks to the drop. Slight differences in temperature make con- 
siderable difference in the result. (Langlois makes use of this in his 
method. He changes the temperature of the fluid in which the drop 
swims, then, when the drop no longer moves, he reads the temperature 
and reckons the specific gravity from this.) 

The specific gravity of the serum may be tested by filling a tube 
with the blood. It is then sealed at both ends and allowed to stand 
upright until the serum has separated well from the clot. The tube is 
then broken and a drop of the serum tested in the same way as the 

10 Wien. kl. Wochenschr., 1890, p. 1018. 



462 



CLINICAL DIAGNOSIS 



blood. That of the plasma may be tested by filling with blood a glass 
tube which has been washed out with 3 per cent, oxalic acid to prevent 
clotting. This is then sealed, the cells allowed to sediment, and 
the supernatant plasma examined. Hammerschlag considers that this 
small amount of oxalic acid will not affect the result. 

In conclusion, the Hammerschlag method looks easy and is simple, 
and yet the possibilities of error from a bubble of air in a drop, the 
evaporation of the mixture, imperfect mixing of the two component 
fluids, and the change in specific gravity of the blood from contact 
with this mixture are great. 

The specific gravity of normal blood has been variously stated. 
Ehrlich considers that it varies normally from 1058 to 1062, the 
average for man being 1059, for woman, 1056. The figures given by 
Piper are, for man, 1055; for woman, 1053; for children, 1051. 
Landois states the average is 1054, the normal limits being 1045 to 
1075. Lloyd Jones places the limits at 1036 to 1068, and Hammer- 
schlag from 1056 to 1063. It is seen from the above figures that 
the specific gravity of the blood of a woman is slightly less than that 
of a man. At birth Lloyd Jones found it 1066. It drops, reaching a 
minimum of 1048 to 1050 in the second year, and then rises to a maxi- 
mum, which obtains between the ages of thirty-five and forty-five, 
of even 1058; after the menopause the average is 1054. The rise in 
adult life may continue to even 1066. Diet has little effect. Menstrua- 
tion, Schmalz says, is followed by a slight increase. Daily variations 
are noted by Schmalz, the maximum between 7 and 8 a.m. being 
1060.7, an d from 11 a.m. to 8 p.m. 1058.8. The specific gravity for 
the serum and the plasma is about the same; from 1029 to 1032, 
an average of 1030. The specific gravity of the plasma, while much 
more uniform than that of the total blood, nevertheless is diminished 
in dropsical condition. 

Using the Hammerschlag method, twenty-three of our students, normal 
men, ages between twenty and twenty-five, found their blood to vary from 1051 to 
1065. In the case of sixteen of the twenty-three it was from 1057 to 1061 ; the 
mean of all was 1058. 

In pathological conditions the specific gravity of the blood may 
vary from 1025 to 1068, in most cases running parallel to the haemo- 
globin. It is reduced in all anaemias, especially in chlorosis. It is 
reduced in many cachexias, in which case the change is in the plasma, 
for the haemoglobin may be practically normal. It is increased in 
fevers from 1057 to 1063, in cyanosis, in obstructive jaundice. 

Until the introduction of the Miescher haemoglobinometer the 
specific gravity was the best method for the determination of the 
haemoglobin, especially in some anaemias as chlorosis, in which cases 



THE BLOOD 



463 



the change in specific gravity is due almost entirely to the variations 
in the amount of haemoglobin. In cases with hydremia, however, 
this rule does not hold, since there the loss is also due to changes in the 
water of the plasma. 

It has been found that 10 per cent, haemoglobin is equivalent to 
4.46 per mille specific gravity, but with the haemoglobin the same 
specific gravity can vary even 13.5 per mille. If the color index is 
changed, the element of the stroma enters even from 4 to 5 per mille, the 
absolute amount of haemoglobin being the same. In leukaemia the 
haemoglobin thus estimated is too high, while in pernicious anaemia 
about 2 per cent, too low. In cases of hydraemia the method cannot be 
used at all ; for instance, in cases with dropsy, anaemia from malnutri- 
tion, post-hemorrhagic anaemia, and circulatory disturbances, in which 
the plasma is considerably affected. In fact, about the only condition 
in which it has been used with good advantage is in chlorosis. The 
specific gravity of the plasma is fairly constant, the change in the water 
affecting especially the red blood-cells. This is true even in severe 
blood diseases, as, for instance, in pernicious anaemia. Since the 
Miescher instrument has come into use there is no longer very much 
value in this method for haemoglobin determinations. 

Dried Residue. Hygrometry. — A weighing glass with a ground- 
glass stopper is first carefully dried and weighed. A little blood 
is then introduced, the cover is put on, and it is weighed again. 
It is then dried for twenty-four hours, or to constant weight, at a 
temperature from 65 0 to 70 0 C, and then its weight determined. 
The solids of the blood in the case of the normal man average about 
21.6 per cent.; for the woman, 19.8 per cent. The figures of Aska- 
nazy are, for man, from 20.35 to 22.89; average, 21.92 per cent.; 
woman, from 19.58 to 21.46; average, 20.53 P er cent - 

For the study of anaemias it was hoped that this would throw im- 
portant light upon the condition of the blood, since it was found to 
run not parallel to the specific gravity nor to the count of the red 
blood-cells, nor to the haemoglobin, and it thus seemed an independent 
element. Its value has, however, not proved as great as was hoped. 

Sedimentation of the Blood.' — The estimation of the volume of the 
red blood-corpuscles would it was hoped dispense with the hard and 
tedious process of blood-counting, since men said, after all it is not so 
much the number of the red blood-cells as the volume of haemoglobin- 
containing protoplasm which is important. The volume of the red 
blood-cells may be determined by the centrifuge method with the 
haematocrit and undiluted blood (see page 449), or the centrifuge, the 
blood diluted with an equal volume of potassium bichromate 2.5 per 
cent, or Muller's fluid. The value of the results by this method is 



464 



CLINICAL DIAGNOSIS 



hardly great, since the compressibility of the red blood-cells seems to 
vary in different conditions. 

The spontaneous sedimentation of the red blood-cells is recognized 
as a more accurate method than the centrifuge. 

Marcano's method: Sodium sulphate solution, sp. gr. 1020, 100 
cc. ; sodium chloride, 1 gm. ; formalin, 3 cc. 

In a special pipette the blood is diluted four times with the above- 
mentioned fluid, and then blown into a graduated conical glass and 
allowed to stand twenty-four hours. The volume of the red blood- 
cells may then be read directly. 

The normal volume is 50 per cent. In chlorosis it often runs as low 
as 20 per cent., while in pernicious anaemia even 9 per cent., in general 
depending on the count, but the determination of which it cannot 
replace. 

Coagulation. — The results obtained have until recently varied so 
widely that but little confidence can be placed in them. The time 
required for the coagulation of the blood outside of the body depends 
upon many conditions, and uniformity of technique is very important ; 
among other things it depends upon the time the blood is in contact 
with the tissues of the incision, the coagulation being slower from a 
deep cut than from a superficial one (a difference of three minutes) ; 
upon the pressure made on the skin to force the bleeding; upon the 
amount of blood allowed to flow; the nature of the vessel which 
receives it; and upon the temperature. The second drop of blood 
coagulates more readily than does the first, and the last drops from 
a wound may clot even ten minutes faster than the first, while in the 
same individual at the same time the blood taken from different parts 
of the body coagulates with different rapidities. Again, the time varies 
at different hours of the day'; being shorter in the morning than in 
the afternoon ; it should not be tested soon after a meal, since the 
time is influenced by certain foods and drugs. 

Added to all these variable factors is the belief that coagulation 
outside of the body is in some way a different process from intra- 
vascular coagulation, so that " we cannot bring the appearance of 
coagulation in the living vessel into direct parallel with coagulation of 
blood as ordinarily understood'' (Welch). For instance, in typhoid 
fever, anaemia, and cachexia thrombosis is common, yet the fibrin con- 
tent of the blood is low ; while in pneumonia and acute articular 
rheumatism thrombosis is seldom, and yet the fibrin content is high. 
Yet concerning the rapidity of clot formation in the wound, the point 
of greatest interest to the surgeon, the results of experiments give us 
the hope to obtain a fairly correct idea from our clinical methods. 

The blood may be obtained from a well cleansed finger or ear. 
The flow must be free and pressure avoided. The first drop is wiped 



THE BLOOD 



4G5 



off and the second used. The time is reckoned from the appearance 
of the drop on the skin. Only drops which well up are to be used. 
The hemorrhage may be retarded by pressure between drops. 

Among the older methods is Hayem's, who received the blood into a gradu- 
ated cylinder and considered it coagulated when the cylinder could be tilted 
without the blood mass changing shape. Another way was to receive a large 
drop on a clean side and test its consistency from time to time with a needle. 
Others put on a cover-glass and watched for the appearance of fibrin with the 
microscope. The above have been discarded, since the results were never uniform. 

Vierordt's Method. — This method has simplicity to recommend it. A white 
horse-hair 10 cm. long is boiled in alcohol and ether. A capillary tube 5 cm. long 
and of 1 mm. bore is thoroughly washed and dried also in alcohol and ether. 
A drop of blood giving a column about 5 mm. long is received into the tube and 
the white horse-hair run through it. Each minute the hair is pulled slightly 
through the drop. The first appearance of coagulation is shown by a slight red- 
dish stain on the hair, which after the blood is well coagulated will again appear 
clean. It is of greatest importance that that part of the horse-hair which is to 
come into contact with the blood should not have been touched with the fingers. 
The amount of blood should be exactly the same each time, since the coagulation 
time depends directly upon the amount of blood. 

All results should be confirmed by a second determination. 

Wright's Method. — The apparatus as commonly used consists 
of a dozen capillary tubes and a small vessel in which water is kept at 
the required temperature. The tubes are numbered and a certain 
amount of blood drawn into each, the time of their filling being regis- 
tered. After minute intervals the tubes are examined by blowing 
slightly into them, and the appearance of coagulation is detected by 
the readiness with which the drop will move. No tube can be twice 
tried, hence the tubes must be examined in such an order that various 
intervals of time may be represented. While the tubes are waiting, 
they should be kept at a temperature of either 37 0 C. or, better still, 
1 8. 5 0 C. This method Ehrlich considers gives comparable results. 
It is one in common use, and yet Wright has recently repudiated it, 
and uses fine capillary tubes into which a measured amount of blood 
is drawn. The presence of a clot is detected by blowing the blood out 
onto blotting-paper. 

The method now; considered the best is that of Russell and 
Brodie. A microscope is necessary. The apparatus consists of a moist 
chamber with a glass bottom which can be placed upon the stage of 
the microscope, while the upper surface is a truncated cone of glass 
projecting downward into the moist chamber. The lower surface of 
this is of a definite size (about 4 mm. in diameter), and on it is placed 
a drop of blood, care being taken that the drop only just covers the 
surface, hence is always of the same size. The glass is then quickly 
fitted into the moist chamber. Through the side of this chamber 
projects a fine tube, through which, by means of a bulb, a gentle 
stream of air can be directed against the blood. With the low power 

30 



466 



CLINICAL DIAGNOSIS 



of the microscope the cells are then watched as thus agitated until 
they are seen to move in clumps. 

This method is the most accurate yet devised. The original appa- 
ratus of Russell and Brodie 1 1 has been modified recently, a much 
cheaper one devised by Pratt, in which the glass cone is dispensed 
with, and a still better one by Boggs. The Boggs apparatus has the 

advantage of a metal tube and the 
improved glass cone, although the 
peripheral jacket, in which water of 
a certain temperature can be circu- 
lated, is not present, nor is this very 
necessary. (See Fig. 99.) 

As little blowing and at as long 
intervals as possible should be done. 
The corpuscles will at first move 
freely and independently of one another (see Fig. 100, A), then in 
clumps on the periphery, B. As the process of coagulation continues, 
the masses of corpuscles will no longer move in the drop, but the drop 
changes shape en masse, the corpuscles showing first an elastic concen- 
tric motion, C, and finally an elastic radial motion, D ; that is, the cur- 
rent of air will cause the masses of corpuscles to move toward the 





IP 




n 

11 


1 


c 


\ A 





Fig. 99. — Coagulometer of Russell and Brodie 
as modified by Boggs. A, moist chamber; B, cone 
of glass the lower surface of which holds the drop 
of blood ; C, side tube ; D and E, cover-glass ; 
at E, a pinhole. 







Fig. 100. — Diagram to illustrate the movement of the cells during coagulation. 



centre, and to quickly spring back to their original position when the 
current of air ceases. This is taken as the final point, since only now can 
a clot be demonstrated if the disk be quickly removed and the drop be 
touched to a piece of filter paper. All clots should be confirmed in this 
way. Sometimes a " vicious circle" is set up in the drop, which clots 

11 Journ. Phys., May 12, 1897. 



THE BLOOD 



467 



everywhere but one point where the blood remains fluid. Such a 
drop should be discarded and another attempt made. It is due to too 
hard blowing. 

Successive records at intervals of 5 to 10 minutes should not vary- 
over 30 to 45 seconds. 

Millian's method is a modification of Hayem's. This method which is con- 
siderably in vogue among the French is to place a drop of blood on a clean 
glass slide, to cover it by a crystallizing dish to prevent very much evaporation, 
then at stated intervals to tilt the slide, and from the change in shape of the drop 
of blood can be determined the coagulation point. By using this method most 
remarkable results have been obtained, the coagulation time extending even into 
hours. The method has been tested under Dr. Boggs's direction in this clinic by 
Messrs. Hinman and Sladen, who have found that very much depends on the 
size of the drop of blood and the evaporation. 

The coagulation time to be considered normal will depend not 
alone on the instrument, but on what is considered the end-point. 
Using the Boggs instrument Messrs. Hinman and Sladen found it to 
vary from, three to eight minutes, an average of five minutes and six 
seconds, a longer time than some others, since they chose a later point 
as the end. (Brodie and Russell, three and a half minutes; Murphy 
and Gould, three minutes, eleven seconds ; Pratt, four to five minutes. ) 
Above nine minutes means delay in coagulation. 

So many methods of such varying value have been used that it 
is difficult to put in order the findings concerning the coagulation. 
All are, however, unanimous concerning the following point: In the 
hemorrhagic diatheses the coagulation time of the blood is immensely 
increased. In some cases of haemophilia it requires fifty minutes, 
while in certain of the purpuras from ten to fifteen or more. In 
long-standing jaundice the coagulation time is increased, a point which 
interests surgeons, and in this clinic in cases of jaundice with delayed 
coagulation an operation is never performed until it has been de- 
creased to about five minutes by a long course of calcium chloride. 
The coagulation time is diminished in stasis due to any cause, after 
repeated hemorrhages, transfusion, hunger, by calcium chloride, and 
by carbon dioxide. In this clinic the gelatin injection method for the 
Cure of aneurism has been given a fair trial and was finally abandoned, 
and further work throws considerable doubt on the value of the method. 
In this connection it has been shown that the gelatin of commerce 
contains considerable calcium, and that if decalcified gelatin be used 
the results are quite different. 

Fibrin Diagnosis. — If very thick smears of blood be made, the 
fibrin may be seen to radiate in strands through the specimen, usually 
from masses of platelets. These smears are allowed to stand for hours 
under the bell- jar. If desired they may then be washed by a gentle 
stream of water which will remove the haemoglobin, and the fibrin 



468 



CLINICAL DIAGNOSIS 



left may be stained with fuchsin and the specimen mounted. When 
examined fresh the specimen should be closed with vaseline to prevent 
evaporation. Those diseases in which most fibrin is seen are pneu- 
monia and acute articular rheumatism. In the former case it is 
suggested as a differential point against tuberculous pneumonia. 

BACTERIOLOGY OF THE BLOOD * 

Before undertaking cultural studies on the blood the observer must 
have a thorough working knowledge of the principles of bacteriological 
technique. We shall therefore consider below only such special points 
as may be useful in applying general bacteriology to the study of 
the blood. 

Technique. — The success of blood-cultures is in part dependent 
upon the obtaining of a sufficient quantity of blood for observation, 
15 or 20 cc. being the usual amount withdrawn. In general, the 
median basilic or cephalic vein is chosen for the operation, the needle 
being passed through the skin into the vessel selected. If for any 
reason these be not available, a smaller vein on the dorsum of the 
hand or foot may be used. Incision of the skin to expose the vein, 
while practised by some, is not generally to be recommended, as it 
increases the discomfort to the patient. In very fat or cedematous 
individuals, however, we may be obliged to divide the skin and sub- 
cutaneous fat to find any vein large enough for use. 

If the cleansing of the surface be carefully carried out, the chance 
of contamination by skin organisms is negligible. 

Ordinarily, the site of operation is scrubbed with green soap and 
hot water, then rubbed over with saturated solution of potassium 
permanganate, followed by oxalic acid, washed with ether and alcohol, 
and then covered with a wet bichloride ( 1 in 1000) compress for an 
hour or more before the puncture. If there be haste and the usual 
materials for cleansing wanting, the skin may be briskly rubbed with 
a sponge of cotton or gauze slightly moistened with pure carbolic acid 
until a faint whitening is visible, and then plentifully washed with 
95 per cent, alcohol and the culture made at once. Properly carried 
out, this latter method gives perfect cleansing, and usually no incon- 
venience to the patient, though a slight transient dermatitis with 
desquamation may result. 

The syringe should be of the usual antitoxin type, and have a 
capacity of 20 cc. Care should be used in selecting one which has 
the glass barrel perfectly true throughout its length. 

The packing of the piston should be of asbestos and very tight. 
Such a syringe may be boiled with impunity. In place of the ordinary 
washer for the needle a piece of soft black rubber tubing should be 

* For this section I am indebted to Dr. Thomas R. Boggs. 



THE BLOOD: BACTEEIOLOGY 



469 



cut and, after perforating with a pin, slipped over the nipple. This 
withstands boiling longer and gives a tighter joint. 

The needle should be short and stiff, sharp, and of moderately 
large calibre, and may be of steel or irido-platinum. To sterilize, the 
syringe and needle are boiled fifteen minutes, or they may be sterilized 
in the autoclave. It is well to have a forceps boiled and use this in 
putting the needle on the syringe. Do not use the syringe until cool, 
as the heat may materially hasten the coagulation of the blood. 

A moderately tight bandage is placed proximal to the site of opera- 
tion to distend the vein, and the needle plunged through the skin, 
which may be anaesthetized with ethyl chloride spray, directly into the 
vein. The piston is drawn slowly and the syringe allowed to fill with 
blood. If the bandage is removed before withdrawing the needle, 
there will be no flow of blood to distress the patient. After with- 
drawal, the needle and washer are removed and the media inoculated 
quickly. Always pass the tip of the syringe through the flame of an 
alcohol lamp before inoculating each tube. 

Agar tubes melted and cooled to about 45 ° C. are used for making 
plates. Bouillon and litmus milk in flasks containing 100 cc. are pre- 
ferred for fluid media. Or a number of tubes may be substituted for 
each flask. The plates should be poured at once. A medium of ox-bile 
and peptone is now considered best for Bacillus typhosus. 

The amount of blood in each tube or flask is varied somewhat 
according to the type of organisms suspected to be present, from 
equal parts of blood and agar to one volume of blood in five of agar; 
in flasks 1 to 2 cc. in 100 cc. of medium. In general, we increase 
the amount of blood where the feebler growing organisms as gono- 
coccus or pneumococcus are suspected. 

The members of the colon group grow better in flasks of bouillon, 
the pneumococcus better in milk. Anaerobic cultures may be made in 
the ordinary ways. 

If after twenty-four hours' incubation the plates show only a few 
surface colonies, contamination may be reckoned upon. Only deep 
colonies occurring alike in several or all plates should be used for 
subculture. True mixed infection in the blood is uncommon. Plates 
and flasks should be examined daily for three or four days before dis- 
carding as sterile, as small colonies deep in the opaque media may not 
appear in the first twenty-four or forty-eight hours. 

Value of Blood Cultures for Diagnosis. — With the increase of 
public and private laboratory facilities in many of our cities blood- 
cultures have become much more available as an aid to diagnosis. In 
many instances they afford the only means of accurate ante-mortem 
diagnosis. 

The pyogenic organisms (streptococci and staphylococci) are 



470 



CLINICAL DIAGNOSIS 



usually readily demonstrated in cases of general infections, osteomye- 
litis or malignant endocarditis being due to their presence. Some 
idea of the intensity of the infection may be gathered from the number 
of colonies per cubic centimetre of blood. 

Typhoid bacilli have been demonstrated in the blood in upward 
of 75 per cent, of a series of cases by Cole, Buxton, Schatmuller, 
Hewlett, and others, often days or even weeks before the Widal test 
is positive. 

In the paracolon infections the isolation of the organism from the 
blood or stools forms the only definite means of differentiation. 

In pneumococcus infections the percentage of positive cultures is 
less but still large, the organism being found principally in the graver 
cases. 

Among other organisms of less frequent occurrence in the blood 
during life may be mentioned : B. aerogenes capsulatus, B. coli, B. 
pyocyaneus, B. anthracis, etc. 

As blood-culture involves but little inconvenience to the patient, 
it may be repeated if the first be negative or demand confirmation. 

AGGLUTINATION PHENOMENA 

Through the action of certain bacteria on the tissues there are 
produced in the blood soluble bodies known as agglutinins. These 
agglutinins, when sufficiently concentrated, have the property of 
clumping and rendering non-motile the specific organism whose activi- 
ties gave rise to their production. 

The nature of the interaction between the bacteria and the 
agglutinating serum is unknown. Theoretical discussion of the phe- 
nomena would carry us too far. afield. 1 2 

Gruber- Widal Test. — This is the agglutination phenomenon ap- 
plied to the diagnosis of typhoid fever. 

Cultures. — A standard stock culture of B. typhosus should be 
kept for this purpose. An organism cultivated through many genera- 
tions on artificial media is preferred. 

From this stock fresh cultures on agar are grown from twelve to 
twenty-four hours for use in the test. Some authorities prefer 
fresh (ten to eighteen hours) bouillon cultures from the stock. Others 
use bouillon cultures killed by the addition of carbolic acid, formalin, 
or other toxic substances. Hastings has devised a method, based on 
analysis of Ficker's " Typhus diagnosticum," which yields very satis- 
factory, and stable-killed cultures, — viz. : To a mixture of aqueous 
5 per cent, carbolic acid, 5 cc, of glycerin, 10 cc, of sterile 0.8 per 
cent, sodium chloride sol., 85 cc, are added the organisms scraped from 

12 For full presentation with literature, see Paltauf, Kolle u. Wassermann's 
Handbuch der path. Microorganismen, Bd. iv. Teil i. S. 645. 



THE BLOOD: SERUM DIAGNOSIS 



471 



two twenty-four-hour agar slant cultures of the typhoid bacillus. The 
bacilli being gradually and thoroughly rubbed into the solution with 
a small spatula, allow to stand five or six days before using. This 
is used by mixing with equal volumes of the diluted sera. Living 
fluid cultures may give rise to confusion from the presence of clumps 
due to the growth of the organism. Of the dead cultures, those 
killed with weak carbolic are preferred, as formalin may cause pre- 
cipitation of proteids from the serum in flocculi. 

The emulsifying of the fresh culture from agar (rather dry slants 
are best) in 0.8 per cent, salt solution, or in bouillon, seems to offer 
the most satisfactory results. This is very readily accomplished by 
means of a rather stiff loop, a loopful of the growth being rubbed 
against the side of the tube of salt solution until thor- 
oughly broken up and then gradually mixed with the 
fluid. The size of the loop gives a fairly quantitative 
measurement of the amount of culture used and the at- 
tainment of a suspension free from clumps is easy. 

Collecting the Blood. — Glass tubes two inches in 
length by one-quarter inch in diameter are drawn out 
into a capillary at either end and kept on hand for the 
purpose. (See Fig. 101.) 

From a free flowing puncture in the ear or finger- 
tip the blood is drawn into the tube by capillary attrac- 
tion until it is two-thirds full. The tube is then placed 
flat on a table until the blood has clotted and the serum 
is separated from the coagulum. The tube is then filed 
and broken at a point just beyond the clot and the serum 
withdrawn with a capillary pipette. If a centrifuge is 
available, the process of separation may be hastened and 
the yield of serum increased by sealing the tip of tube 
which is free from blood in a flame and centrifugalizing 
a few minutes, when the clot and corpuscles will be con- 
densed in the lower end and the serum left as a clear 
layer above. If it is desired to preserve the specimen or 
to send it away, both its ends may be sealed in the fig. 101.— Tubes 
flame or with sealing-wax. Serum is best kept after sep- ^^/bio!^ 
aration from the corpuscles in a sterile tube. If larger a, blood is clotting 
amounts of blood are required, a vein should be aspirated Xt now^etrlctinJ 
with the syringe as in the procedure for blood-culture. from the sid es. £, 

Diluting Serum. — To obtain the dilution of serum f^ d 1 t ^ entnfugal " 
used in the reaction a number of methods are employed. 
A simple and very satisfactory method is as follows : A piece of one- 
quarter-inch glass tubing is drawn into a long capillary, as shown in 
cut. This is plunged into the serum in the collecting tube and the 



472 



CLINICAL DIAGNOSIS 



capillary allowed to fill, care being taken to avoid stirring up the cor- 
puscular layer. From this capillary the serum is dropped into the 
tubes or dishes in which the dilutions are to be made. A small water- 
color palette of porcelain is very convenient for making a number of 
dilutions. Salt-cellars or watch-crystals may be used. As a routine 
at least two dilutions of each serum should be made, i to 10 and i to 50. 

For this purpose we proceed as follows : To the first drop of 
serum we add 4 drops of 0.8 per cent, salt solution dropped from 
the same pipette, which has been washed out with distilled water 
to remove any trace of serum, and then dried in the flame. To the 
second drop of serum 24 drops of salt solution are added giving 
dilutions of 1 in 5 and 1 in 25. Now, the addition to an} r portion of 
these dilutions of an equal volume of the suspension of the typhoid 
culture will give us dilutions of 1/10 and 1/50. In the same way 
any desired dilution may be made. If greater accuracy or very high 
dilutions be required, special mixing pipettes similar to the Zeiss 
melangeur for blood counting may be employed. Again, dilutions 
may be made directly from the whole blood with such a melangeur, 
using salt solution as diluting fluid and counting each two volumes 



Fig. 102. — Tube used for diluting serum. 

of blood as one volume of serum. The mixture is allowed to settle 
or, better, is centrifugalized before using. With the diluted serum we 
can now proceed to the macroscopic or microscopic tests. 

A. Macroscopic Method. — This method depends on the agglu- 
tination of the organisms into, clumps visible to the naked eye and 
the eventual precipitation of the clumps, leaving a clear supernatant 
fluid. The serum is diluted in a test-tube of small calibre, and the 
organisms added either as a suspension of living or killed cultures ; 
or, what is perhaps more convenient, the full dilution, as 1 in 50 or 
1 in 100, is made with salt solution and the organisms from solid 
culture suspended directly in the diluted serum, as described in the 
foregoing section. The tube is then examined by strong transmitted 
light to see that its contents are homogeneous and free from acci- 
dental clumps. A narrow band of light from a lamp enclosed by a 
screen aids in detecting the early appearance of clumping. A positive 
test is reckoned if there be general clumping at a dilution of 1/50 or 
higher in one hour with complete precipitation, leaving a clear super- 
natant fluid after twenty-four hours. The reaction is hastened if the 
tubes are placed in the thermostat. 

This method has the advantage of simplicity in that no microscope 
is required and that killed cultures may be employed, thus obviating 



THE BLOOD: SEBUM DIAGNOSIS 



473 



the necessity for a thermostat and culture media. The " Typhus 
diagnosticum" of Ficker, 13 now so widely used in Germany, is a prepa- 
ration of killed cultures, the formula for which is kept secret. More 
complete details of this method and its results will be found in a 
recent paper by Borden. 14 

Several pharmaceutical laboratories in this country now make and 
sell killed cultures for the macroscopic Widal. 

B. The Microscopic Method. — The diluted serum may be 
mixed with the requisite volume of the typhoid suspension by the use 
of pipettes, as above noted, and a drop of the mixture taken for obser- 
vation on a hanging drop slide. Or we may mix the two on the 
cover-slip directly. To do this we use a platinum loop of stiff wire, 




Fig. 103.— Widal test. Field of motile organisms. X 900. 



the plane of the loop being at right angles to the handle and the 
diameter of the loop being constant. The loop is dipped vertically 
into the serum dilution and the drop so obtained placed on the centre 
of the cover-slip. The loop is flamed off and dipped into the typhoid 
suspension in the same way, and the two drops thoroughly mixed on 
the cover-slip. Approximately equal volumes are readily obtained 
by this simple method, enabling us to secure any desired dilution. 
The cover-slip is then inverted over the well of a hanging drop slide 
which has previously been ringed about with olive oil or vaseline, 
and the preparation is then ready for examination. The hanging drop 
is observed with a moderately high dry lens (Zeiss D, or Leitz 1/6 
in.), and is seen best by artificial illumination. The Argand burner 
or oil-lamp with a yellow flame is preferred. The light is stopped 
down with the diaphragm so as to bring out the refractivity of the 
bacteria. 

13 Berl. klin. Wochenschr., 1903, No. 45. 

14 Medical News, March 18, 1905. 



474 



CLINICAL DIAGNOSIS 



The freshly made hanging drop should be free from clumps and 
show the organisms actively swimming about in addition to their 
Brownian motion. (See Fig. 103.) After the lapse of one hour, 
if the test is positive, the organisms will be seen to be collected entirely 
in clumps and to have lost their motility; this at a dilution of 1/50 
or higher. (See Fig. 104.) The presence of two or three free 
organisms in a field otherwise well clumped is considered not to 
vitiate the test. 

It is frequently noticed that the clumping is better at the higher 
dilutions, while there may be very marked bacteriolysis at 1 in 10 
or 1 in 20 or even higher dilutions. Many normal sera will give 
perfect agglutinations at 1 in 10, and show no trace of the reaction 




Fig. 104. — Widal test. Field of agglutinated organisms. X 900. 



at i in 50 or higher dilutions. Hence tests based on the low dilutions 
alone are unreliable. The macroscopic method has rapidly gained 
favor in the best laboratories, and is probably less open to error than 
the microscopic, provided strict limits of time and dilution (one hour 
at dilution of i in 50 or higher) are observed. There is so much 
variation in the determination of microscopic clumping by different 
observers that it is often difficult to compare their results. Some 
authors consider any aggregation of a very few organisms agglu- 
tination. These differences have led to much confusion, particularly 
in experimental work. 

Agglutination with Dried Blood. — This method is based on 
the use of blood dried on glass, tin-foil, or glazed paper, and is only 
accurate where the blood is carefully weighed and the dilution based 
on weight instead of volume. Its sole recommendation is the con- 
venience with which the blood so dried may be transported. 



THE BLOOD 



475 



Value of Agglutination Reactions in Typhoid Fever. — While the 
Widal reaction very rarely fails to appear in typhoid fever, it may be 
long delayed and is not often present before the seventh or eighth 
day, so that it is often no aid to early diagnosis. Still, it remains our 
most certain confirmatory test and is indispensable in abortive, doubt- 
ful, and obscure cases. 

The persistence of the agglutinative reaction is variable, the limits 
being from a few weeks to many years. Some cases of long persistent 
Widal have been attributed to the presence of typhoid bacilli in the 
gall-bladder, in gall-stones, or in the urinary bladder. 

The agglutination of B. typhosus by normal sera at the standard 
dilutions, i /50 in one hour, is so rare as to be negligible. 

The question of " associated agglutinations " in which the serum 
agglutinates two or more organisms closely related, as B. coli, B. 
alkaligines, and B. typhosus, is too complicated to find place here. 
Suffice it to say that the limited time and the high dilution employed 
in our tests is sufficient to give us reliable specific results. 

Paracolon Infections.— While these often give highly specific 
agglutinations, the presence of associated agglutinins should be con- 
sidered and the diagnosis of any one type of paracolon by agglutina- 
tion reaction only would be open to error unless cultures are made 
for confirmation. 

Other Agglutinations. — The agglutination reactions have been 
applied to many different organisms with more or less definite results, 
but in most cases they have not reached any considerable diagnostic 
value and are often very difficult of application. 

Those specially interested will find full details in the references appended. 

Dysentery group: Flexner, Bull. Johns Hopkins Hosp., 1900; also Centralbl. 
f. Bakt, 1901, Bd. 30. Shiga, Centralbl. f. Bakt, 1878, Bd. 23, 24. 

Tubercle bacillus : Arloing and Courmont, Compt.-rend. Ac. de sc., 1898, t. 
127, p. 312; Zeitschr. f. Tuberkulose, 1900, Bd. i. H. 1, 2. Frankel, Hy. Rund- 
schau, 1900, No. 13. 

Streptococcus : Van de Velde, Arch, de Med. exp., Paris, 1897. Neufeld, 
Zeitschr. f. Hygiene, 1903, Bd. 44. 

Meningococcus : Jager, Zeitschr. f. Hyg. u. Inf., 1903, Bd. 45. 

Malta fever : Wright, Lancet, March 6, 1897. Strong and Musgrave, Phila. 
Med. Journ., 1899. In Malta fever the reaction is on a well-established practi- 
cal diagnostic basis. 

Paracolon : Korte, Zeitschr. f. Hyg., 1903, Bd. 44. Coleman and Buxton, 
Am. Jour. Med. Sci., 1902. Schottmuller, Deutsch. med. Wochenschr., 1900, 
p. 511. 

RED BLOOD-CELLS. 

The erythrocytes are specialized non-nucleated cells, which con- 
sist of haemoglobin, 95 per cent., and stroma, and whose chief func- 
tion is to carry the oxygen to the tissues, and to a lesser degree the 
carbon dioxide to the lungs. 



476 



CLINICAL DIAGNOSIS 



In shape they are circular, discoid cells, which in well-made fresh 
specimens lie flat. In many of them a biconcavity is apparent, but in 
normal blood this must be looked for pretty sharply, and in many 
cells is not seen at all; in some conditions, especially the secondary 
anaemias, it is very evident. The opinion of Weidenreich and Lewis, 
that in the circulation these cells are not flat but are cap-shaped, is 
borne out in many specimens, especially those from the bone-marrow; 
clinically it is a point of no importance. Cells of normal blood, unless 
subjected to considerable mechanical injury in making the smear, are 
perfectly round and of a size varying from 6 to 9 microns in diameter. 
When they are not round, or are of very abnormal size, the term 
" poikilocyte" is applied to them (Plate I, 25-28). Such cells occur 
in pernicious anaemia especially, even of a mild grade, and in other 
anaemias of severe grade, especially in cases of cancer, tuberculosis, 
etc. They are probably due to alterations in the plasma. 

Structure. — These cells are about the hardest of all to study, being so sensi- 
tive. Various methods have been applied to demonstrate their structure, and each 
has shown a different one. Foa's description, a peripheral structureless haemo- 
globin-containing layer, a middle with a net-work of fibres enclosing granules, and 
a centre of homogeneous protoplasm, is one of the most elaborate and often 
quoted. The consensus of opinion now is that all of the fibres, layers, etc., are 
artefacts ; that the various granular-like bodies seen in the fresh cells are not an 
essential part of the cell ; that those in the stained are, some at least, precipi- 
tates of the fixing agent, or of the stain ; and that structure, although it cer- 
tainly exists, is yet to be demonstrated. Ehrlich considers that heat is the best 
fixative, because it gives a homogeneous cell without structure. This argument 
seems weak, for heat renders difficult of observation the structure of many other 
cells of similar nature, including the protoplasm, but not the granules, of leuco- 
cytes, and hence may be the very worst method for the study of red cells. 

Not only is their fine, but also their coarse structure in dispute. The cell 
membrane formerly believed to exist, then doubted, is again claimed by Deetjen, 
who describes it as elastic, gelatinous, glassy, and stained best in underheated 
specimens ; while others claim merely a haemoglobin-free concentration of the 
stroma at the surface. 15 Since so many believe the nucleus to disappear within 
the cell, they think it necessary to find some remains of it there. The question 
of the nucleoid is in dispute, some considering it to be related to the nucleus and 
others to be totally independent. 16 The word " nucleoid" has a variety of mean- 
ings in the writings of at least six observers who have employed it. It means 
among others the " differentiated inner body of Lowit ;" that is, a nucleus-like 
structure in the centre of the red blood-cell which in certain specimens is very 
apparent, it taking a basic stain ; it has a fibrillar structure, and a central clear 
space ; in its centre again is a differentiated inner body, which " may be extruded as a 
platelet." " The nucleoid develops after the extrusion of the nucleus (Maxi- 
mow)," but Lowit considered it the remains of the now invisible nucleus. Against 
these as parts of the cell is to be urged that constant technique is necessary to 
give constant results ; that their size varies from very small to that two-thirds of 
the corpuscle ; their periphery is indistinct often, and radially striated ; that is, 
they do not look " genuine." It is hard to believe that Maximow can tell the age 
of red cells by this inner structure. 

The non-nucleated red blood-cells when fresh certainly look structureless.- Al- 



See Peskind, Am. Jour. Med. Sci., 1904, vol. cxxiv. 
Maximow, Arch. f. Anat. u. Physiol., 1899. 



PLATE I. 



Cells of Normal Blood. 

1. Small lymphocyte; small mononuclear. 

2. Eosinophile leucocyte. 
3, 4. Large lymphocytes. 

5. Transitional mononuclear. 
6, 7. Polymorphonuclear neutrophile leucocytes. 
8. Mastzell. 



Cells Found in Splenomyelogenous Leukemia. 

9, ii, 17. Neutrophile myelocytes. 

10. Dwarf polymorphonuclear neutrophile leucocyte. 

12, 13. Transitional cells between myelocytes and polymorphonuclear cells. 

14. Eosinophile leucocyte. 

15. Lymphocyte. 

16, 19, 20, 21. Large mononuclears. 

18. Dwarf polymorphonuclear eosinophile leucocyte. 

22. Polymorphonuclear eosinophile leucocyte. 



Erythrocytes in Chlorosis. 

23. Cells found at the height of the disease. These are the "doughnut" or " pessary" 

forms. 

24. Cells from the same case as 23 during convalescence. 



POIKILOCYTES IN PERNICIOUS ANAEMIA. 

25. Battle-door form. 

26. Sausage form. 

27. Microcyte. 

28. Megalocyte. 

Nucleated Red Blood Cells. 

29. Mature normoblast. 

30. Immature normoblast. 
31, 32. Intermediate forms. 

33. Megaloblast. 

34. Normoblast with nucleus showing fragmentation or incomplete mitosis. 

35. Fuchsinophilic normoblast. 

36. Leucocyte of the same size as 37 shown for comparison 

37. Large nucleated red cell. 

38. Intermediate nucleated red (or megaloblast), the "reptilian form." 



PLATE I. 




25 



AT HEIGHT OF DISEASE. 



ERYTHROCYTES 
IN CHLOROSIS. 



SAME CASE DURING 
CONVALESCENCE. 



POIKILOCYTES 
IN PERNICIOUS AN/EMIA. 





ALL STAINED WITH EHRLICH'S TRIPLE STAIN 
AND DRAWN TO SAME SCALE. 



LEUCOCYTE FOR 
COMPARISON. 

NUCLEATED RED BLOOD CELLS. 



F. S. Lockicood. 



THE BLOOD: BED CELLS 



477 



most every staining method will give a different result, and yet it is certain that 
they have some structure, that they have a discoplasm or the " oikoid ;" a stroma 
which may be seen after the haemoglobin has been washed out ; but the various 
" inner bodies," etc., seen may be nothing but masses of degenerated protoplasm, 
the Maragliano endoglobular degenerations, and in the light of present knowledge 
all may be considered artefacts. Only perfect cells are seen in the circulation. 
They enter it as almost perfect, and they leave it before marked signs of age are 
apparent (see page 479). 

Size. — In the adult these cells vary from 6 to 9 microns in diameter 
with an average of 7.5 microns. Hayem found that 75 per cent, 
varied from 6.6 to 8, 12.5 per cent, from 6 to 6.6, and 12.5 per 
cent, from 8 to 9 microns in diameter. These limits are quite fixed in 
the adult, although a very few dwarf cells do occur at all ages. But 
in the normal infant blood the cells vary much more, with normal 
limits of 3.3 to 10.3 microns. In disease the adult blood may resume 
this infantile condition. Evidence is given that the red blood-cells of 
various nationalities differ somewhat, the size diminishing as one 
approaches the equator. In the fresh blood occur physiological rhyth- 
mical changes, the cells being somewhat larger in the venous than 
in the arterial blood where they are charged with oxygen (Ham- 
burger). Pathologically, they vary much in size. 

Microcytes. — This term means cells under 6 microns in diameter. 
The smallest are about 3.5, and yet some are 2.2 microns. There is 
doubt whether all these are perfect cells or are schistocytes, — i.e., frag- 
ments of larger cells, — since the process of constriction of small frag- 
ments from the red blood-cells can be followed in the fresh blood and 
be produced by pressure on the cover-glass, etc. For the cells above 
3.5 microns in diameter we can find nucleated reds of corresponding 
size which represent young forms. These are seen in perfect fresh 
specimens. Such cells have no biconcavity as a rule, are spherical, 
and hence have a deep color. They occur normally in the embryo 
infant, and especially in premature children. In these cases they are 
often polychromatophilic. They are found rarely in the healthy adult, 
but are common in all anaemias, especially the primary and severe 
secondary anaemias. 

Macrocyte is a term applied to cells from 9 to 12 microns and 
above in diameter; for cells from 12 to 16 microns, the term megalo- 
cyte; and for those above 16 microns, gigantocyte. These cells 
occur in largest numbers in pernicious anaemia. Some believe that 
if 10 per cent, of the reds are macrocytes a diagnosis of pernicious 
anaemia is justified. They also occur in leukaemia and in chlorosis. 
In chlorosis they are often very pale, hence the term " chlorotic " or 
" dropsical " cells. They are also very common in cases with cholaemia, 
which is of interest since cases of pernicious anaemia are so often 
jaundiced (Osier). That their size is due to hydraemia is considerably 



478 



CLINICAL DIAGNOSIS 



in dispute; it is well known that plasma is quite constant in its water- 
content, and that the variations in water of the total blood affect 
especially the cells. Whether the chief difference between the small 
dark cells and the large pale cells is the amount of water, each having 
approximately the same amount of haemoglobin, is the question. In 
pernicious anaemia the largest cells are sometimes the darkest, and 
some of the microcytes are exceedingly pale, while in secondary 
anaemia the reverse is true. (See Plate I.) 

Staining Properties. — Red blood-cells like all other cells while alive 
are achromatophilic, and take a stain only in proportion to their death 
changes. If the red cell is killed by a good fixative which prevents 
post-mortem changes, all normal cells are monochromatophilic, and 
since they take only acid stains from a mixture, are acidophilic. With 
most dyes it is the haemoglobin especially that takes the stain, and 
changes in this will show themselves to a certain degree by the tint and 
the tone which the cells take. 

Cells which take other than the acid component of a stain either 
as a whole or in part are termed polychromatophilic or basophilic. 
By this term (a synonym of which is " anaemic degeneration") we 
do not now include the basophilic granules to be described later. 
Eosin stains the basophilic cells more faintly than the normal, and 
if followed by a basic stain, such as haematoxylin, will be supplanted 
by it. A basic stain should not color a normal red unless it is in an old 
dried smear. Ehrlich's triple stain is unsuitable, since methyl green 
is too feeble a basic stain, and the acid components too much in excess 
to show the basophilia well. 17 Basophilic corpuscles are usually larger 
than the normal, have less biconcavity, and often are poikilocytes. 
With haematoxylin and eosin such cells take a violet tint; with the 
Ehrlich, a fainter tone than normal, or a grayish color; with poly- 
chrome methylene blue stains a bluish violet ; in all cases, basophilic. 

Ehrlich explains basophilia as a coagulative necrosis. In favor 
of this are, that other signs of degeneration are also present; that it 
can be produced in animals by inanition ; that these cells are present 
within twenty-four hours after a haemorrhage, that is, before any 
nucleated cells or other signs of active regeneration have appeared; 
and that it affects especially the megaloblasts. The other view is 
that they are young cells. Others say that the granules are evidence 
of incomplete intracellular oxidation. Basophilic cells occur in per- 
nicious anaemia; in the grave secondary anaemias, especially those due 
to cancer; in the eruptive fevers, malaria, the 'purpuras; and after 
various blood poisons. 

Other cells are " fuchsinophilic " (Plate I, 35) ; that is, stained 

17 See Walker, J. of Bost. Soc. Med. Sci., November, 1890. 



THE BLOOD: BED CELLS 



479 



with Ehrlich's triple stain they are very red. Since so many of the 
nucleated reds of the marrow are fuchsinophilic this is considered 
a sign of a young cell. (These cells are usually distorted, as if very 
soft.) The same is said of the basophilic cells, for nearly all nucleated 
red cells are slightly basophilic, but basophilia and fuchsinophilia are 
not the same. 

While the middle ground is usually unsatisfactory, yet there is, 
we think, the best of evidence that young red cells in general are 
basophilic, and good evidence that a degenerating cell will usually 
take such stains. The same may be said for microcytes, macrocytes, 
and the basophilic granules; it is hard to say whether they are signs 
of regeneration or degeneration, but since they occur in such a variety 
of conditions it is improbable that they have always the same signifi- 
cance. They are not signs simply of anaemia, for anaemia may be 
severe without them, yet in general all abnormal corpuscles — abnormal 
in size, shape, amount of pigment, nucleation, with protoplasm having 
abnormal staining affinities, etc. — are grouped as " anaemic forms," 
and the explanation is of little importance. To us basophilia as evi- 
dence of youth is interesting, since it was Theobald Smith who first 
suggested it in a case of purpura and later emphasized it in his studies 
on Texas fever. 18 Walker found such cells in the normal blood of 
all lower vertebrates ; and in the foetus of the dog and guinea-pig even 
ninety times as many as in the blood of the mother. In normal marrow 
the basophilia is in inverse proportion to the amount of haemoglobin 
that the cells contain, judging by the fresh specimen before staining, 
hence the term " anaemic degeneration;" but this lack of haemoglobin 
could be primary or result from the loss of some from the cell. 19 
Walker suggests that these "cells hurried into the circulation while 
too young" are as good an index of anaemia as the blood-count, 
and their detection much easier. Germani also emphasizes them as 
an important feature of the blood picture in severe anaemias, their 
number being in direct proportion to the severity of the case, and, 
since easy to stain, suggests them as a valuable hint in diagnosis and 
prognosis. 

Engel's opinion that the fuchsinophilic cells represent a related 
yet different type from orthochromatic cells (i.e., cells staining in 
the usual manner), and that they send cells into the blood-stream only 
in anaemia when the supply from the orthochromatic nucleated reds 
is exhausted, has not received much support. Taylor says fuchsino- 
philic cells are not found in embryonic or infantile blood. We would 
object to this most emphatically, since that is where we have found 
the best illustrations of these cells. 

18 Walker, loc. cit. 

19 See also Stengel, Contrib. from Pepper Lab., Univ. of Pa., 1900. 



480 



CLINICAL DIAGNOSIS 



Partial polychromatophilia is best illustrated by the Maragliano 
endoglobular degeneration (see p. 433). these degenerated areas stain- 
ing well with a strong basic dye, especially methylene blue. The 
probability is that many of the so-called " inner bodies," " nucleoids," 
and other so-called evidences of cell-structure are nothing but these 
stained areas of degenerating protoplasm, which sometimes resemble 
malarial parasites, and the extrusion of which gives rise to bodies 
resembling platelets. Their resemblance to malarial parasites is so 
striking that we know one eminent pathologist who admitted that 
had he not been sure that before death a patient had not malaria he 
would have been unable to say that the inclusions in certain red blood- 
cells stained with hematoxylin and eosin were not malarial parasites. 
These degenerations certainly led to many mistaken diagnoses before 
the chromatin-staining mixtures were used. 

The ring bodies described in some of the red cells of anaemic blood 
by Cabot, 20 and which require for their demonstration the polychrome 
methylene blue-eosin mixtures, are, he suggests, nuclear remains. 
They are red rings, ovals, or bands, evidently not related to the 
stippling of the cells. They occur especially in pernicious anaemia, 
but also in the leukaemias and various secondary anaemias. 

In heated specimens, if this be done too quickly, or if they be 
exposed to moisture, around the periphery of the cell may sometimes 
be seen a row of large dots, which are neither true granules nor do 
they resemble the granules in malaria. 

In certain cases of malaria (those we have seen have all been 
tertian and from the Tropics) the infected cells show a remarkable 
granulation (Plate III, 10, 13). They contain granules which are 
of quite uniform size, which are as coarse as the eosinophile granules, 
and stain purple in the Hastings'' stain, while the rest of the cell stains 
paler, in fact may be almost colorless, as if the haemoglobin had been 
condensed into these clots. (This is merely a "descriptive explana- 
tion.") We have seen cells in which the granules appeared hung in 
a hyaline envelope around the parasite. They can be seen in the fresh 
unstained cell; the lead granules cannot (Boggs). We are sure these 
are not artefacts, and that they are not the same as the granules of 
lead poisoning which also may be present in the cells. One who has 
seen both will not identify them. 

The " methylene blue degeneration of Ehrlich" is the name given to 
a beautiful picture seen in specimens of fresh blood stained by this dye, 
the cell containing a mesh- work of fibres. 

" Vital Blood-Staining." — To study these granules and fibres 
in the unfixed cells, one puts on the wet smear a granule of methylene 
blue or neutral red. then the cover is sealed at once to the slide with 

20 Journ. of Med. Research, 1903, vol. iv. p. 15. 



THE BLOOD: BED CELLS 



481 



paraffin, and the beautiful threads of fine granules are soon seen. 
Whether these are preformed, or signs of death or degeneration, or 
merely precipitates of stain in the cell, is uncertain. 

Another excellent method of vital blood-staining was used by 
Rosin. 21 A cover-glass is lightly spread with the saturated alcoholic 
solution of methylazur or of toluidin blue, which is then allowed to 
dry. Over this stained surface a blood smear is made, and the surface 
at once inverted over a hollow slide with vaselined rim. The blood 
can be watched for even twenty-four hours. These methods are not 
used nearly enough. 

Various poisons, potassium chlorate, pyrogallic acid, et til., often 
will produce vacuole-like areas or clumps in the cells, which are 
motile and which may break free from the cell, or the cell may be 
dissolved leaving them free. Heinz and Bloch describe these as 
" areas of poisoned protoplasm." 

The Basophilic Granulation of Grawitz (Plate II, 22, 24, 
25). — In certain conditions, especially lead poisoning, pernicious 
anaemia, leukaemia, etc., certain of the red blood-cells when stained with 
any good basic stain, particularly gentian violet or methylene blue, 
contain minute granules. They are not seen in fresh unstained speci- 
mens ; they are not increased by allowing the blood to stand. 

While any methylene blue-eosin mixture will do, the most beautiful speci- 
mens are prepared as follows. The air-dried smears are fixed for from three to 
five minutes in absolute alcohol, washed in water, and while still wet are stained 
with Loffler's methylene blue for a few seconds or much longer, then dried, or 
examined in water. The bluish-black granules stand out against the clear green 
corpuscles. 

A beautiful stain to differentiate these from fragments of the nucleus, which 
many suppose them to be, is that of Pappenheim (Boellke). 

Stain I. Acid, carbol. liquefact., 0.25 ; aqua dest, 100 ; methylene green 
(pur.), 1. 

Stain II. Acid, carbol. liquefact., 0.25; aqua dest., 100; pyronin (pur.), 1. 

Fifteen cc. of I. and 35 cc. of II. are well mixed and filtered. The blood- 
smear fixed by heat (not alcohol) is stained for a few seconds with the filtrate. 
The fragments of nuclei are deep greenish-blue, the granules bright red. 

In a severe case one finds as many as five or six of these 
" stippled cells " in a field, but, as a rule, several fields must be searched 
in order to find one. There may be but one or a few granules in a 
cell, but as a rule it is well sprinkled, and to such a degree that some 
consider that the tone of a polychromatophilic cell is due to them. 
They may be from dust-like size to a micron or more in diameter. 
They occur anywhere in the cell, but are distributed quite regularly as 
a rule. Many think they are situated in the external layers of the 
protoplasm. They occur in the severest anaemias, especially the 
primary pernicious, in which they are large and conspicuous ; in sec- 

21 Rosin and Bibergeil, Zeitschr. f. klin. Med., 1904, vol. liv. p. 107. 

31 



482 



CLINICAL DIAGNOSIS 



ondary anaemia due to cancer, especially of the gastro-intestinal tract; 
in cachexia ; in leukaemia, in which cases they are not numerous ; and 
in septic processes ; while in chlorosis some say they are rare, others 
(Stengel and Pepper, in n of 18 cases) common. They also occur 
in phthisis, lues, chronic parenchymatous nephritis, small contracted 
kidney, cirrhosis of the liver (Grawitz). In gout they are many in 
number, and yet in rheumatism with even severe blood changes they 
are very rare. Few are found in tuberculosis, typhoid fever, pneu- 
monia, lues, nephritis, etc. In gout it is of interest that especially 
large numbers are found in those cases with haematoporphyrinuria ; 
Guyot found them regularly in the hemoglobinuria due to cold; in 
tuberculosis Grawitz says they occur only after the secondary in- 
fection of a cavity. That condition in which they occur in the largest 
numbers is lead poisoning. They are found in the blood of Europeans 
who have recently moved to the Tropics. 

Grawitz interpreted them as areas of coagulated necrosis and they commonly 
now bear the name " Grawitz basophilic granular degeneration." 22 White and 
Pepper, 23 Stengel and Pepper, 24 Bloch, and others agree. 

On the other hand they are normal in embryonic blood, never, some say, in 
adult blood ; nucleated reds often contain them, good evidence against their 
relation to a degenerating nucleus. They are often present in the degenerated 
reds, but also occur independently of other degenerations, as polychromatophilia, 
poikilocytosis, etc. Their relation to malaria and to polychromatophilic degenera- 
tion is now generally abandoned. Others say that they are in some way or 
other related to new formation of cells, while now and again recurs the view 
that they are related to the nucleus. 

Cadwalader distinguishes three groups of granulated corpuscles ; those with 
the granules in fine and coarse thread-like strands ; those with fine dot-like granu- 
lations ; and those with dense coarse masses. The first type is found in small 
numbers in normal blood ; the second, the most common form, in lead poisoning 
and pernicious anaemia ; the last in those cases of lead poisoning in which nu- 
cleated reds -are plentiful. These, last granules, in position and size, suggest a 
breaking-down normoblast nucleus. The reds are otherwise normal. Others 
deny that transitional stages between fragmenting nuclei and these occur, and 
point out that they are least in the bone-marrow where karyorrhexis is most 
common. Again, it is claimed that they do not occur until definite signs of 
regeneration have also occurred (but the hydraemia is also at its maximum then), 
well seen in post-hemorrhagic anaemia, hence the opinion of some that they are 
related to regeneration. In favor of this is the difficulty of producing them by 
the direct influence of lead salts. 

Cadwalader 25 finds them always associated with nucleated reds in lead poi- 
soning, and thinks them the result of a fragmentation of the nucleus of the red 
cell. In favor of this is the fact that the increase in nucleated reds precedes that 
of the granulated cells, and he thinks the forms of granules suggest steps in the 
process. 

At this point we wish to state that those dealing with these granules do not 
exclude any other basophile granules, hence practically every granule found in 
red blood-cells is described under this one title. In our opinion there are at 

22 Hamel, Deutsch. Arch. f. klin. Med., May 23, 1900. 
22 Am. Jour. Med. Sci., September, 1901. 

24 Am. Jour. Med. Sci., May, 1902. 

25 Bull, of the Ayer Clin. Lab., Univ. of Pa., January, 1905. 



THE BLOOD: EED CELLS 



483 



least three different basophilic granulations in red blood-cells, that these when 
compared side by side have little resemblance the one to the others, and, we sus- 
pect, no relationship ; but the scope of this book could include a discussion of 
the latter point only in so far as it emphasizes their appearance or occurrence. 

The malarial granules are described on page 480. Compare them side by side 
with the Grawitz granules, and they do not seem to belong to the same class of 
structures. Grawitz believed them different, but did not state reasons. The one 
cannot be seen in the fresh cell, the other can. 

The granules described by Vaughan (see page 435) as remnants of nuclei do 
not resemble the Grawitz granules, and yet from Cadwalader's figures we judge 
he includes them as his coarse variety. It is impossible to say they are not 
related, but they do not look as if they were. 

Perhaps their greatest importance is in lead poisoning, since here they may be 
the only abnormal blood-feature. In other diseases in which they occur, as the 
anaemias, they form but a minor part of the blood picture, although they occur in 
large numbers. They are very fine in size. Some claim that they can be found 
in the blood of all lead-workers. This may be the case, but it depends on the 
length of time that the specimen is studied, and we do find cases of lead poison- 
ing, particularly the peripheral neuritis cases, the one condition in which it would 
be most important to find them, in which they have not been found, or only 
one cell, in the time at the disposal of the ordinary clinical worker. They are 
especially numerous in cases >with gastro-intestinal features, to which symptoms 
they bear a rough parallelism, but this may be better explained by the fact that 
both are early features of lead poisoning. They vary much in number from 
day to day. As a rule they appear very early, even after four days' exposure to 
lead, and they may be present in the blood of those exposed over twenty years. 
They are the first sign of the anaemic blood changes, and the last sign to disap- 
pear, hence we may speak of an anaemia even before the count drops. In the 
diagnosis of intestinal colic they may be of importance, but in the cases of 
peripheral neuritis we have failed to find them so. 

Other references to this subject are, Naegeli, 26 who considers them related to 
blood regeneration ; Boellke, 27 who denies that they bear any relation to the 
nucleus. 

Number of Red Blood-Cells. — The average count for the normal 
adult man is usually given as 5,000,000 cells per cubic millimetre of 
blood; for the woman, 4,500,000. In a healthy young man, how- 
ever, it is more common to find from 5,000,000 to 6,000,000. 

By polycythemia is meant a condition with more cells per cubic 
millimetre than this present; by oligocythemia, one with a smaller 
number. It is evident that this number is simply relative, that varia- 
tions may be due either to actual variations in the number of red 
blood-cells in the body, or to the amount of plasma, which may by 
diluting the blood cause an oligocythemia, and when it is reduced in 
amount, a polycythemia. 

The blood-count may vary in different parts of the body. Oliver 28 
found that anything which increases the blood-pressure even locally 
will cause a rise in the count at that point ; as, for instance, in a limb 
that has been hanging in a dependent position, active or passive motion, 

26 Munch, med. Wochenschr., 1904, No. 5. 

27 Virch. Arch., 1904, vol. clxxvi. S. 47. 

28 Brit. Med. Jour., 1896. 



484 



CLINICAL DIAGNOSIS 



digestion, etc. These variations are, however, quite slight; yet ex- 
ercise will raise the count, the local application of cold and of heat 
lower it or raise it, according to the production of stasis, vasodilata- 
tion, or constriction. 

Excessive exercise, Willebrand found, would raise the count of red 
cells from 3 to 23 per cent, (average 12.3 per cent.), and of leuco- 
cytes from 19 to 97 per cent, (average 47 per cent.). 

Physiological Variations. — The effect of sex has already been 
mentioned. This variation occurs only during the menstrual period 
of life, since for girls until their fifteenth year the count averages 
5,444,000, while for boys of the same age 5,102,000; between the 
ages of forty and sixty, again the count of women averages 5,000,000. 

The count varies much with age. The maximum is at birth, in 
which case it may be even 7,000,000, but, as a rule, is lower, — e.g., 
5,740,000 (Stengel and White). Otto found the average for the 
first four days to be 6,155,000; in one child ten hours old, 6,910,000. 
It depends somewhat on the time at which the umbilical cord is tied, 
since by tying late there may be a gain of almost one million cells 
per cubic millimetre. After the first four days the count begins to 
drop, and is at a minimum in about one year. These high counts at 
birth are probably due to the concentration of the blood; the 
body is not yet accustomed to its environment, and loses considerable 
water. They last but a few days, not over ten, after which nucleated 
reds also disappear. 

From birth until about the tenth year the count reaches the mini- 
mum, then slowly rises. There is considerable difference of opinion 
when this minimum occurs. Gundobin gives the average count during 
this period as 5,100,000. It. rises from puberty to thirty years of 
age, during which period young healthy persons often have from 
5,500,000 to 6,000,000 cells. From about thirty to fifty years, 5,000,- 
000 for men, 4,500,000 for women, may be considered normal, and 
after forty the count is inclined to slowly drop in men and rise in 
women. 

Not satisfied with the age curves usually quoted in text-books, we have at- 
tempted one, using the material of this clinic, especially the neurasthenics and a 
few patients with apparently normal blood. In addition to this we have the very 
valuable studies of our medical students on their own blood, counts made to 
conform to the most rigid criteria of accuracy (see page 447), as accurate, we 
believe, as any which have yet been published. 

We have used means, not averages ; this is, we think, the correct way of arriv- 
ing at a fair estimate of blood-counts, etc., for the extremes should not be con- 
sidered when the question is of the most common condition. All the figures are ar- 
ranged in order of magnitude, and that chosen as mean around which the greatest 
number clusters. For a discussion of the low haemoglobin estimations, see page 
499. 



THE BLOOD : RED CELLS 



485 



Blood of Patients. 



Males. 









Hb mean 






Years. 


Cases. 


Reds (mean). 


Per cent. 


Index. 


Leucocytes. 


6 to 1 5 


5 


5,560,000 


85 




750O 


16 to 25 


36 


5,200,000 


85 


0.8 


650O 


26 to 35 


69 


5,300,000 


90 


O.85 


7000 


36 to 45 


42 


5,500,000 


90 


O.82 


^OO 


46 to 55 


21 


5,300,000 


80 


O.75 


9000 


56 to 65 


9 


5,000,000 


80 


0.8 




66 and over 


5 


4,000,000 


60 


0.77 


7500 






Females. 






10 to 15 


5 


5,000,000 


75 


0-75 


8000 


16 to 25 


43 


4,500,000 


77 


0.85 


750O 


26 to 35 


55 


4,500,000 


80 


0.88 


7200 


36 to 45 


34 


4,600,000 


72 


0.80 


770O 


46 to 55 


17 


4,500,000 


77 


0.85 


7000 


56 to 65 


10 


4,500,000 


70 


0.78 


6O0O 


66 and over 


3 


4,700,000 


65 


0.7 


7000 



The students' counts showed the following : age, twenty to twenty-five years ; 
males, 176 cases; mean of reds, 5,000,000 (extremes 4,500,000 and 6,700,000) ; 14 (8 
per cent.) were below 5,000,000, and 15 (8.5 per cent.) above 6,000,000) ; of leuco- 
cytes, 7500 (52 cases) ; of haemoglobin, 14.5 gms. (Miescher), 92 per cent. 
(Fleischl), 95 per cent. (Dare), 92 per cent. (Gowers). 

Females, 16 cases ; mean of reds, 4,800,000 ; of leucocytes, 8000 ; of haemo- 
globin, 11 gms. (Miescher), 85 per cent. (Fleischl), 87 per cent. (Dare), 82 per 
cent. (Gowers). 

Nutritional Conditions. — In thin muscular persons the count is 
somewhat higher than in the stout. A large meal may cause a tem- 
porary slight decrease, said to be due to the increased fluid of the 
plasma. During hunger periods there is an increase, a rise of a half- 
million cells in twenty-four hours being common, attributed to con- 
centration of the blood. 

The temperature has an influence on the count. In winter there 
are about 500,000 more cells per cubic millimetre than in summer (this 
was well seen in some of our students' counts). The change of resi- 
dence from temperate zones to the Tropics may lead to a drop in the 
count of from 500,000 to 2,000,000 cells. 

Pregnancy. — For both mother and the foetus there is said to be a 
diminution in the count during the last part of pregnancy ; for the 
mother a drop of about half a million cells and 20 per cent, of haemo- 
globin ; for the foetus of from seven and a half to eight and a half 
months the count was found to be 7,000,000, while at nine months 
6,500,000 (Biondi and Gardini). The blood of mother and child are, 
on the whole, rather independent; in case the mother has an anaemia- 
producing disease the child can preserve its count fairly well, and vice 
versa. 



480 



CLIXICAL DIAGNOSIS 



Thompson made a very careful study of twelve cases in Dr. Williams's clinic 
of this hospital. He found a moderate decrease in the reds from the fourth to 
the eighth month. The count and haemoglobin rise to normal at term. The 
specific gravity shows the most striking curve parallel to that of reds and haemo- 
globin, but more accentuated, with the initial fall and terminal rise, the minimum 
(1040.8) at the sixth month. 

Altitude. — A great amount of work has been done to decide this,, 
one of the most vigorously debated chapters of hsematology. The 
rise in count in persons ascending to high altitudes is a phenomenon 
long ago witnessed, but its explanation is not yet wholly clear. The 
count increases as persons ascend at the rate of about 50,000 cells per 
one thousand feet, and diminishes as soon as they descend, or at the 
latest thirty-six hours after. The increase in the count is especially 
marked after a sudden ascent to a considerable height ; there is little rise 
from an ascent of 1200 metres, it is slight and tardy after an ascent of 
1800 metres, but immediate and considerable after an ascent of 3000 
metres. The rise is certainly more rapid than could be explained by 
a new formation of blood, and on the descent there are no signs of 
blood destruction. The rise is best seen in invalids, especially those 
with lung tuberculosis. The symptoms of anaemia are even aggravated. 

There would now seem to be two factors which enter into the case, — the first 
a temporary one, due to a changed distribution of the blood-cells, and later, in 
eight or ten days, a permanent change due to a true new formation of cells. 

Miescher and his pupils consider that the diminished oxygen tension is the 
stimulus to new blood formation, confirmed by the work done in many laboratories 
and by many men, Jaquet et al. Evidence of an increase of blood was found in 
animals kept for several days in an atmosphere of reduced tension, or by keeping 
these animals at high altitudes. And yet practically all of this experimental work 
has been challenged, and animals sent to high altitudes give disappointing results. 

Other explanations were given :— that there was a concentration of the blood 
due to evaporation (Grawitz), hardly possible, since the solids of the plasma do 
not change as much as the count; that it was an accumulation of cells in the 
capillaries (Tuntz) ; that the cells lived longer; that there was an initial fragmen- 
tation of the reds causing the early increase, and then a true new formation 
(Koppe) ; that there was a peripheral vasoconstriction causing a concentration of 
the blood from the increased lymph formation (Bunge) ; and lastly, that it was 
due to the error in the instrument, the reduced atmospheric pressure affecting in 
some inexplicable manner the thickness of the stratum of blood counted (Gottstein). 
So many papers have recently appeared on this subject that we shall mention but a 
few, especially that of Campbell and Hoagland, 29 who consider that the change is 
due simply to a changed distribution in the blood-cells, depending on the lowered 
blood-pressure, this due to the lowered barometric pressure, and to a compensatory 
increased heart action, hence the pulse increases almost parallel to the count. Mosso 
showed peripheral vasodilatation, hence stasis in dilated capillaries, at altitudes. 
The heart will compensate all these factors if the person remains at an altitude, 
hence later the count returns to normal. The difference in temperature has some 
influence; hence the count at Colorado Springs is about 800,000 lower than at the 
city of Mexico, two places of the same elevation. Some consider this the chief 
factor (Weinzirl, et al). Experiments with rabbits showed a decreased count in 
the mesenteric circulation corresponding to the rise in the peripheral circulation. 

29 Am. Jour. Med. Sci., November, 1901; 



THE BLOOD: RED CELLS 



487 



The experiment of Gaule, who studied his blood during a balloon ascension and 
found the rise accompanied by the appearance of many nucleated reds, has not 
been confirmed. 

Drugs and Therapeutic Measures. — Among the drugs which 
increase the count by their effect on the reds are iron, which is almost 
a specific in chlorosis, affecting especially the formation of haemoglobin, 
and arsenic, a drug equally valuable in pernicious anaemia, which 
seems to affect the production of the red blood-cells. Mercury in 
large doses causes an anaemia. The destruction of weakened cells by 
this drug may explain the Justus test for lues. Lead causes a chlorotic 
anaemia, explained by some by the gastritis, by others by its direct 
injury of the red blood-cells. In favor of the latter view is the granu- 
lar degeneration so constant in these cases. 

Any drugs which affect the amount of plasma by causing rapid 
losses of fluid to the body, as diuretics, emetics, purgatives, dia- 
phoretics, will cause a rise in the count, providing the change be 
sufficiently rapid. Yet one is usually disappointed in the slight effect 
of these drugs. 

Cold baths cause an average increase of 1,860,000 (Thayer). This 
is due to the peripheral vasomotor constriction, hence stasis in the 
capillaries. The specific gravity also is increased. The maximum in- 
crease is immediate, and disappears in about one hour. Breitenstein 
thinks the effect of a cold bath is greater for a typhoid patient than for 
a normal man, since the distribution of cells is already abnormal. 

There is often a transitory post-operative rise of 100,000 to 1,000,- 
000 cells, probably a peripheral phenomenon. 

Pathological Conditions. — The acute cachexias of infectious 
disease, due to the toxins of certain of the specific fevers, can cause 
a marked anaemia, even when there are no hemorrhages. This is 
true in certain cases of pneumonia and of typhoid fever, but is by no 
means common. With the lowering of the count there is increased 
pigment in the urine and increased globulicidal properties of the 
serum. Hence there is probably an increased destruction of the red cells. 

Chronic Cachexia. — Of this tuberculosis, cancer, and lues are the 
best illustrations. (See pages 596, 610, and 615.) 

The methaemoglobin-producing poisons diminish the count, because 
of their direct destruction of the cells. Among these are pyrogallic 
acid, the chlorates, certain of the coal-tar products, as antifebrin and 
phenacetin. 

Other pathological conditions raise the blood-count, as phosphorus 
poisoning, especially acute cases, in which the count has risen in two 
or three days even to 8,650,000. Since the solids of the plasma are 
not correspondingly increased this rise is not due to globular concen- 
tration, and in some cases there is no vomiting at all. The cause is 



488 



CLINICAL DIAGNOSIS 



uncertain. The same is true of carbon monoxide poisoning, in which 
counts of 6,630,000 have been reported in cases without vomiting. 

In cyanosis, particularly that due to congenital heart disease in 
which the count may be from 8,000,000 to 9,000,000, but also to a 
less degree to lung and other heart troubles, especially mitral, the 
count may be exceedingly high ; or when the color is extreme the count 
may be normal. In local cyanosis, that due for instance to hemiplegia, 
there may be a local rise in the count. In lung disease, especially 
emphysema, acute miliary tuberculosis, and pneumonia, the count is 
high ; in emphysema and heart disease, even 7,000,000 ; in adherent 
pericardium, above 6,000,000; in Reynaud's disease there is a local 
rise at the affected parts ; while in a very interesting group of cases 
of cyanosis, first reported as an independent disease by Osier, 30 the 
polycythemia is extreme, the highest on record, in one case reach- 
ing 10,200,000, in another case, 10,000,000. In all these cases the 
cause is very doubtful. Some explain it as a change in the distribution 
of the blood, some as a concentration from loss of plasma, others as 
an over-production of red blood-cells ; others say these are longer- 
lived than normal ; while most admit that they do not know. 

Osier reviewed nine cases, four of which he reports. The cyanosis was ex- 
treme, lasting even for years. The highest count was Cabot's, of 12,000,000, and 
but one was below 9,000,000 (8,250,000) ; haemoglobin, 120 to 150; specific gravity, 
1067 to 1080 ; leucocytes, 4000 to 20,000, but most below 10,000. This publication 
of Osier's has stimulated a good many reports of cases with high counts. Zam- 
firescu reports the case of a woman with cyanosis, dyspnoea, and cough ; reds, 
7,000,000 to 7,300,000; haemoglobin, 105 to 116; leucocytes, 9000 to 10,000. Kikuchi 
reports a case with bronchiectasis. Turk 31 reports seven cases like Osier's, two 
with autopsy, with counts from 7,700,000 to 10,600,000. He suggests that the cyano- 
sis is not due to deficient aeration of the blood, but to a crowding of vessels with 
an excessive number of cells ; that these cases are not rare, but are diagnosed as 
pseudoleukaemia or hypertrophic liver cirrhosis ; that the enlarged spleen is not 
the primary lesion ; that this is a primary hyperplasia and increased function 
of the erythroblastic myelogenous tissue, hence the disease is analogous to leukaemia, 
except that there the hyperplasia is of the leukoblastic marrow elements ; in favor 
of this is also the constant presence of abnormal red cells and of myelocytes. 
Other interesting cases of polycythaemia without cyanosis occur, as Zandy's, 32 who 
proposes the term " erythrocytosis." His was also a case of splenomegaly ; the 
count was even 9,500,000. Turk 33 reports a case with cirrhosis of the liver and 
enlarged spleen, with a count of 9,300,000 ; leucocytes, 37,000 ; haemoglobin, 18.2 
gms. Gresbock 34 mentions cases with nothing but the high count. 

The counts locally high are especially important, for one count- 
ing blood must exclude them by not taking his drop from a blue ear 
or finger. 

30 Am. Jour. Med. Sci., 1903, vol. cxxxvi. 

31 Wien. klin. Wochenschr., 1904, Nos. 6 and 7. 

32 Munch, med. Wochenschr., 1904, No. 27. 

33 Deutsch. med. Wochenschr., 1904, No. 50. 
34 Deutsch. med. Wochenschr., 1904, No. 20. 



THE BLOOD: BED CELLS 



489 



There is one point to be borne in mind in this connection, that we 
usually count capillary blood, not arterial or venous, and the count 
in the capillaries need not be the same as that in the vessels. A 
capillary field of the frog's mesentery or rabbit's ear, e.g., is seen 
to contain few corpuscles moving in single file through the capillaries, 
and some channels so narrow that the cells do not enter them at all. 
In cases of active congestion from warmth, or of venous stasis, the 
capillary bed is much widened, the capillaries filled with cells, even 
those which before transmitted only plasma ; hence the count is higher. 
It is not so much changes in the relation between plasma and tissue 
lymph which can cause very rapid changes in the capillary count while 
that in the arteries may remain constant, as factors governing filling 
and circulation of the capillary area. The count in capillaries and veins 
is about the same. Following more marked changes in temperature, 
as e.g., after a cold bath, the count does rise in the arteries, since then 
the flow to the tissues is increased. 

These changes are much more marked in the leucocytes than in the 
reds, since the former collect in the vessels, forming layers along the 
walls. 

Cyanosis may deceive one much, as, for instance, in a case with 
normal blood-count which at autopsy shows a condition suggesting 
pernicious anaemia. The same is true of certain dysenteries. 

Similar cases with high counts follow the use of various coal-tar 
products. 

A student recently handling aniline oil became cyanotic ; red cells, 5.900,000 * 
haemoglobin, 107 per cent. (Dare) ; leucocytes, 6100. Six days later the reds 
were 5,084,000, haemoglobin, 78 per cent. (Dare). 

Resistance of the Red Blood-Cells. — Many methods have been 
proposed for determining the resistance of the red blood-cells, in the 
hope of explaining phenomena such as haemoglobinsemia. At first 
these methods were mechanical, chemical, electrical, but are now 
biological, the side-chain theory of Ehrlich being invoked to explain it. 

Hamburger's Method. — Sixteen small glasses, each containing 1 cc. of 
a sodium chloride solution of various strengths, the lowest 0.4 per cent., and each 
succeeding one 0.03 per cent, higher than the preceding, are used. One drop of 
blood is placed in each, stirred, allowed to stand for six hours, and then exam- 
ined to see if it is laked. Normally the lowest concentration which the cells 
will endure is 0.46 per cent. Since the serum is equivalent to 0.9 NaCl solution, 
it is evident that the cells live in a hypertonic medium. With this method the 
resistance has been found increased in anaemias, in haemoglobinaemia, after many 
poisons, in typhoid fever, erysipelas, pneumonia, and jaundice. The method is 
faulty, however, since in paroxysmal haemoglobinuria the cells have been found 
normal, but of lowered resistance to mechanical disturbance. Stengel proposes 
the following method. The blood is diluted 1 : 10 in a Zeiss leucocyte pipette, 
with sodium chloride solutions varying from 0.42 to 0.52 per cent. The blood is 
mixed and then blown into small tubes sealed at one end. These are allowed to 
stand and then centrifugalized for from two to five minutes, then held against a 



490 



CLINICAL DIAGNOSIS 



white paper to see in which the corpuscles have laked. The advantage of this 
method is that more fluid is used, and that the percentage is not materially altered 
by the salts which escape from the cells. Stengel considers it is not osmosis 
alone, but a chemical or a vital reaction between the stroma and the Hb, which 
holds them together. As a result of his experiments he found that saturation with 
an excess of carbon dioxide (as in congestion) causes no great morphological 
change and no particular alteration in the cells, and yet the vulnerability is 
greater ; that cold produced marked changes, as, for instance, if the congested finger 
be frozen, which is suggestive concerning haemoglobinuria ; that hypotonic salt 
solutions have the power in the test-tube as well as within the blood-vessels 
of decolorizing and vacuolating red blood-corpuscles. This point is disputed by 
many workers, who find that even the intravenous injection of distilled water 
does not lake any blood-cells. Heat of even slight degree changes the shape and 
size of the corpuscles and finally decolorizes them. A higher degree causes bud- 
ding, vacuolation, and a somewhat higher degree complete fragmentation (see 
page 430). 

Mechanical Influences. — In some conditions the cells have been found to have 
varying resistance to shaking. Meltzer has shown 35 that the effect of shaking 
depends upon the rapidity of vibration, that for each blood there is a minimum and 
maximum rate which the cells can bear without destruction. Laker has tested the 
cells by passing the discharges of a Leyden jar through them. Various other 
methods have been proposed, but with as yet little result. 

The Estimation of Haemoglobin. — This should be the easiest and 
the most useful determination in blood- work, and it is unfortunate 
that the use of faulty instruments has resulted in the accumulation 
of a vast amount of data of very little value ; for the estimation of 
haemoglobin is of more importance than the blood-count, as it is so 
much less time-consuming. In the case of the blood-count we know, 
supposing the work has been neatly done, what is meant by the figure 
given ; but for haemoglobin we must know the kind of instrument 
used, its make, and the amount it has deteriorated. In general we 
know remarkably little that is accurate about the haemoglobin content 
of the blood in disease. 

It is unfortunate that instruments do not all read in grammes rather than 
percentage, for their makers do not agree what quantity of haemoglobin should 
be called normal, nor is there a figure which is normal for all ages, since the 
age curve of haemoglobin is very hilly. If instruments are to read percentages, it 
would be well to have one for each of the various periods of life, since the blood 
of a normal child of about ten years would read but 80 per cent, on an instru- 
ment standardized for a normal man of thirty years. Were haemoglobin expressed 
in grammes, there would be less danger of calling such a child " slightly anaemic ;" 
it would also be easier to restandardize an instrument. 

Another element of error is that instruments are standardized against haemo- 
globin in dilute water solution, while haemoglobin in an albuminous fluid like 
the blood-plasma will give higher readings ; hence in reading the blood of extreme 
anaemias we may get misleading figures. For instance, in post-hemorrhagic anaemia 
the haemoglobin would seem to drop much lower than is really the case. 

In judging the various instruments, one should consider the principle on 
which the instrument is constructed, and whether or not the maker has followed 
this principle well. For instance, the v. Fleischl seems well made, but there are 
several inaccuracies in its principle ; the Gowers instrument has fewer inaccuracies., 
but is so poorly made by many manufacturers that it has fallen into disrepute. 



Johns Hopkins Hosp. Rep., vol. ix. 



THE BLOOD: HAEMOGLOBIN 



491 



Miescher's Modification of the Fleischl Instrument (see Fig. 105). — 
This is at present our best instrument. It is, however, for laboratory 
use only, since it is expensive, bulky, and requires a dark room, con- 
siderable time for each determination, and considerable practice. The 
blood is mixed in a beautifully made pipette (see Fig. 106), which 
allows dilutions of 1 : 200, 1 : 300, or 1 : 400. The markings of these 
pipettes are particularly good, especially the small lines on either side 
of each main line, each indicating V100 of the length of the column 
between the tip and the " 1" mark, thus obviating the necessity of 
losing valuable time in trying to bring the blood column exactly to a 
mark. The polished conical end is also an advantage. 

A large drop of blood is aspirated to the point indicated for the 
desired dilution. Such a dilution should be chosen as will allow the 




Fig. 105. — Miescher's modification of Fleischl's haemoglobinometer. A, stage; B, color-prism 
rack ; C, milled head ; D, ceil ; E, cover-glass ; F, cap ; G, cell seen from above ; H, cell of Fleischl's 
instrument. 

readings to be made near the middle of the color-prism. A normal 
blood cannot be diluted to the 1 : 200 mark, since the readings will be 
" off the scale" of the table of equivalents. The diluting fluid used is 
0.1 per cent, sodium carbonate. (A stock solution of 10 per cent, is 
diluted one hundred times.) Distilled water has been recommended, 
but with the dilute soda solution we get a color-tone more approxi- 
mating that of the prism, which materially aids the readings. The 
blood is mixed exactly as for a blood-count, is well shaken, then the 
contents of the capillary tube are blown out. In filling the cells (of 
which there are two, one 15 mm. and the other 12 mm. in depth) it is 
essential first to fill one side with water, to make sure that there is 
no leakage into the other half. The blood, well shaken, is blown into 
the other chamber of the cell. Both the water side and the blood 
side should have convex meniscuses. The cover-glass, E, is then slid on 



492 



CLINICAL DIAGNOSIS 




carefully, pushing off this excess and leaving the chambers exactly 
full. The slightly raised partition prevents mixing. The small cap, F, 
is then put in place, to hold the cover-glass secure and also to limit 
the field of vision to one about 3 0 in length. The cell is then placed 
in the receptacle on the stand, A, and the instrument placed in a 
screen which admits the light at one point only, where it will fall 
directly on the mirror and illumine both sides equally. The light to 
be used is a yellow flame, whether from gas, oil, or candle. Electric 
light, a gas-light with a mantle, or sunlight, cannot be 
used. The person should sit in a comfortable manner 
with the eyes about 25 cm. above the instrument, and 
make his readings with both eyes open. The milled 
head, C, moving the color-prism, is then rotated until 
that part of the prism (see Fig. 107) which just matches 
the color of the blood-mixture is under the water half 
of the cell. In doing this it is well to make quick excur- 
sions to both sides of the point, gradually diminishing 
them until the point of matching is reached. Since the 
retina is soon fatigued, and is not then sensitive to col- 
ors, the eyes should be rested after each fifteen seconds 
of color-matching. A very conscientious, painstaking 
student will sometimes get results much worse than the 
careless student, since through careful work the eyes are 
fatigued. When the color is matched the reading is 
made. At least five such readings should be taken, — 
ten are better, — and the mean, not the average, used. 
The blood is then removed by sucking it up with the me- 
langeur from this (the deep) chamber, the shallow 
chamber filled in the same way, and a similar series of 
readings is made. Since these cells have heights which 
are to each other as 5 is to 4, and since different parts 
of the color-prism are used, if the readings of the lower 
multiplied by 5 / 4 differ from the average made with the 
higher by not over 2 per cent., and the instrument is a 
well standardized one, it is seen that the readings are so 
controlled that considerable error at this point is impossible. We 
insist that the student shall if necessary put the blood back again into 
the deep chamber and repeat the work until the readings with the two 
cells, both calculated for the 15 mm. cell, do not, vary over two points. 

The great advantage of the instrument is that each is accompanied 
by a scale which gives the number of milligrammes of haemoglobin 
per litre of diluted blood corresponding to the readings of that par- 
ticular instrument. It is of the utmost importance that the right book 
be used. It is then easy, making due allowance for the dilution, to 



W 



Fig. 106. — Mix- 
ing pipette of Mie 
scher's haemoglo 
binometer. 



THE BLOOD: HEMOGLOBIN 



493 



determine the number of grammes of haemoglobin in 100 cc. of blood, 
the desired result. If then, with due observance to the age curve, the 
worker wishes to express his answer as a percentage, he is at liberty 
so to do. This instrument has been found to be correct within 0.2 
per cent, of haemoglobin. In case a light screen is not at hand, a 
tube of blotting-paper may be fitted over the cell, thus the side light 




Fig. 107.— Color-prism of the Fleischl-Miescher instruments. 

is screened from the eye over this tube. A person should be careful 
in this case to use the eyes alternately, so that neither may become 
fatigued. 

The mixing pipette is cleaned, etc., just as is that used in blood- 
counting. 

Fleischl Haemoglobinometer. — This, until within a few years, was 
in this country the favorite instrument. The Miescher machine just 
described is an improved form of this. The blood is 
taken in a small short cylindrical capillary tube (see Fig. 
108), which is only a few millimetres long, perhaps 1 mm. 
wide, and holds from about 5 to 8 cmm. of blood. It is 
fastened in a small metal holder by means of cement. To 
wash this in alcohol or ether results invariably in loosen- 
ing the tube, and when once loosened it is so small and 
easily broken that the pipette is as good as ruined. It 
should be cleaned in water, and then by drawing 
through it a needle with a thread soaked in alcohol and 

1 • 1 x m Fig. 108. — Pi. 

then m ether. It must be perfectly dry. The point of pette of the Fiei- 
prime importance is that the number on the handle of schl instrument - 
this pipette shall correspond to the number on the post of the machine,' 
otherwise gross errors will certainly result. This pipette is filled by 
touching its end to a large drop of blood. It should not be stuck into 
the blood, since any wetting of the outside is to be avoided. One 
makes sure that there is no blood on the outside, and that the tube is 
so exactly filled, that the surface of the fluid is flat. Meanwhile, 



494 



CLINICAL DIAGNOSIS 



the cell (see Fig. 105) of the instrument has been filled on the one side 
with water and on the other side by a few drops of water. The pipette 
is dropped into this latter and emptied by rapidly agitating it in this 
water ; then with a few drops of fresh water the drop of fluid clinging 
to it is washed back into the cell. By means of the handle of the pipette 
the blood is then thoroughly mixed with more water, until this chamber 
of the cell is filled to the brim. The two halves should then be exactly 
full, without concave or convex meniscus, and certainly without any 
leakage from one side to the other. They may be covered over with 
a suitable cover-glass. In a dark room the instrument is read as the 
Miescher. 

There are a few precautions to observe. The images of the two chambers 
should fall on the right and left halves of the retina, never on the upper and lower, 
since the lower half of the retina is not nearly so sensitive as is the upper ; the 
light should never be in front of the instrument, but at the side ; as small a 
candle as possible should be used ; if there is no screen handy, a tube of dark 
paper will suffice to cut out extraneous rays. The inconveniences of the machine 
are the following : in the first place, one is looking at a color field of the prism, 
which varies at its extremities by at least 15 0 , and the observer must try to read 
the color at the centre of a field with such wide variation as this (compare the 
cells H of the Fleischl with G of the Miescher). It is difficult to see how a 
person can claim to make readings within 2 per cent. Again, the instrument has 
certainly not been standardized as accurately as is desirable, there being consider- 
able difference between the older and the newer instruments, and even in the 
latter it is stated that the prism has straight sides, which certainly does not 
fulfil the requirements of a good optical instrument, since depth of color is not 
directly proportional to thickness of glass. For this reason all readings should 
be made on the upper half of the prism ; hence, if the blood be known to be 
anaemic at least two or three pipettefuls are employed for each determination. The 
instrument is bulky; it is also expensive. The greatest objection to it that we 
find is that it has the appearance of accuracy without the reality. A person that 
has used no other machine is usually confident that he can read within at least 
2 per cent. We suspect that the error inherent in the machine is at least 5 per 
cent. The observer should be very careful to use his retina not over fifteen 
seconds at a time, to prevent fatigue. To clear the blood in case of lipsemia and 
high leucocytosis by means of ether and potassium hydroxide is not to be recom- 
mended. 

Gowers' Instrument.' — This little instrument (see Fig. 109) is much 
to be recommended, perhaps is the best for the general practitioner. It 
is cheap, easily portable, simple, and should be fairly accurate. It con- 
sists of a color-tube, B, containing a fluid the tint of one per cent, haemo- 
globin solution, and a graduated test-tube, A, into which 20 cmm. 
measured in the pipette, C, are diluted with water until the tints match. 
The percentage is read directly on the graduated scale from the height 
of the diluted blood. 

The blood is drawn to the proper mark in a measuring pipette, 
and then blown into the graduated tube, in which have previously 
been placed a few drops of distilled water. By sucking this water 



THE BLOOD: HAEMOGLOBIN 



495 



back and forth the inside of the pipette may be quite thoroughly 
cleansed of the blood, but it should then be again filled with distilled 
water and this added to wash out the last trace. The blood is mixed 
with the water by covering the end of the tube with the thumb and 
inverting it several times, but the thumb should be wiped across the 
top of the tube, that the clinging drop of water may not be lost to 
the mixture. It is well in reading these two tubes to use both direct 
and transmitted light. They are best held against a sheet of white 




Fig. 109. — Gowers's haemoglobinomefer. A, graduated Fig. iio. — Sahli's 

tube; B, color-tube ; C, pipette. haemometer. 



paper, and it is also well to cover their upper ends by another piece of 
paper, that the reader may not be biased by the height of the column. 
In certain instruments there is a tube for daylight and one for artificial 
light. 

The instrument is not claimed to be accurate within less than about 
5 per cent. In buying this instrument it is very essential to get one 
made by a responsible firm, for the market has simply been flooded 
by cheap instruments which have not a semblance of accuracy. We 
recommend those which bear Sahli's name, since he guarantees their 



496 



CLINICAL DIAGNOSIS 



accuracy. It should be remembered that these color-tubes of gelatin 
stained with picrocarmine certainly bleach, and should be renewed 
from time to time. When not in use they should be protected from 
sunlight. An advantage of these instruments is that no greater ac- 
curacy is claimed than they possess, and one is not tempted to read to 
I per cent. Another advantage is that there is but one color to stand- 
ardize instead of a whole scale. 

The Haemometer of Sahli (see Fig. no). — This instrument has 
been sufficiently tested and certainly is one of the best. The principle 
of this instrument is similar to that of the Gowers, but the color-tube 
contains a I per cent, solution of acid haematin, and the haemoglobin 
of the blood is changed to acid haematin by hydrochloric acid. Acid 
haematin is a pigment which is quite constant in composition and color 
value. The instrument may be used in any light since the two tubes 
contain the same substance and would therefore be modified equally. 
The blood is obtained in the same way as for the Gowers, and blown 
and washed into the graduated test-tube into which has already been 
placed up to the 10 per cent, point a tenth-normal solution of hydro- 
chloric acid. (This may be made with sufficient accuracy by diluting 
15 cc. of the pure acid to one litre with distilled water. Sahli recom- 
mends that a little chloroform be kept in this stock bottle.) The 
hydrochloric acid in a few minutes changes the haemoglobin to acid 
haematin. It is then diluted with distilled water until its tint corre- 
sponds to that of the standard color-tube. These tubes are placed in 
a very convenient little stand with a ground glass back, which renders 
the reading easy and quite accurate. The color-tube is said not to 
deteriorate with age so much as that of the Gowers instrument. 

Dare's Haemoglobinometer.— This instrument (see Fig. 1 11), re- 
cently put on the market, certainly promised very good results. A 
film of undiluted blood is compared with a color-prism stained with 
golden purple. The pipette (see Fig. 112) consists of two plates of 
glass, one white, A, one clear, B, between which is a slit of known 
width. A rather large drop of blood is necessary and will at once 
by capillarity fill the slit. The pipette is then slipped into the instru- 
ment, Fig. 1 1 1, B, and the reading made at once by the light of a candle, 
E, attached to the instrument, not necessarily, however, in a dark room, 
providing the observer faces a black background. On the instrument 
is a telescope tube, A, which allows accurate focussing and also an 
advantageous magnification of the two color-fields, — that of the blood 
and of the color-prism. By means of a small wheel, D, the prism is 
rotated until the colors match, and then the reading is made at the 
knife edge on the edge of the disk. The same precaution of not 
tiring the eyes is to be observed in this as in all other color-tests. The 
advantages of the instrument are that undiluted blood is used ; that 



THE BLOOD: HAEMOGLOBIN 



497 



it is rapid ; that leucocytes do not affect the reading as in the other 
instruments ; and that it can be used in a light room. Its disadvan- 
tages are that certain of the instruments were not well standardized 
when put on the market, and while they may now be, still the read- 
ings are generally rather low ; the instrument is expensive ; the read- 
ings must be made at once before clotting, since in a very few minutes 
the reading jumps from 5 to 10 per cent. It is rather a fragile instru- 
ment and does not stand the wear and tear of hard usage. Neverthe- 
less, it is rapidly cleaned, it is a very convenient, satisfactory, and, 
when well standardized, accurate instrument. We do not recom- 
mend it as superior to the Miescher, and we do not think it enough 



better than the cheaper instruments, especially the new Sahli, to justify 
its high price. We have been very much pleased, putting several 
instruments in the hands of as many workers, to find how closely they 
agree in their readings on the same case. 

The Oliver Instrument. — This instrument is historically important, since it 
was the first accurate instrument proposed to replace the v. Fleischl, which before 
then had been accepted as the standard. It consists of two frames of tinted glasses, 
six disks in each, the colors of these glass disks varying by 10 per cent. The 
blood is obtained in a large automatically filling pipette, is mixed in a cell with 
white base, and covered with a cover-glass. By candle-light the color of this 
mixture is compared with the various glasses until it is decided between which 
two it stands. The eye must be screened by means of a camera lucida from side 
rays. By means of riders of colored glass, which raise the percentage 5 per cent, 
(certain special instruments have a rider for each per cent.), closer readings may 
be made. The instrument is well standardized and well made. While formerly 




Fig. hi. — Dare's haemoglobinometer. A, telescope; B, pi- 
pette in place; C, case inclosing color-prism; D, milled head 
moving prism ; E, candle; F, window admitting light to color- 
prism. 



Fig. 112. — Pipette of 
Dare's instrument. A, the 
white glass ; B, clear glass 



disk. 



32 



£98 



CLINICAL DIAGNOSIS 



it was more accurate than any on the market, it has lately been displaced by the 
Miescher. Many find it is rather inconvenient to use. 

The Tallqvist Scale. — This simple little device was exploited as a 
great boon to the general practitioner. It is a little book of blotting- 
paper and a scale of colors. A drop of blood on the blotting-paper 
is in direct sunlight matched against this color-scale. The instrument 
costs but a dollar and a half, can be carried easily in the pocket, and 
a determination made in less than a minute. The colors of the scale 
vary by 10 per cent., therefore any intermediate percentage must be 
estimated by the eye. We admit that the trained eye, that is, an eye 
trained to use more accurate instruments like the Miescher, will soon 
use this color-scale more accurately than an untrained eye will use 
the Miescher ; but the former can guess as near, even from the color 
of the lips, without the Tallqvist scale, while of one eminent Viennese it 
is said that he could guess within 0.5 per cent, from a stain on cloth. 
This was guess-work, but almost as much so is the Tallqvist method. 
The instrument was standardized against the v. Fleischl, which does 
not recommend it. 

The spot of blood is obtained by holding the edge of the paper 
against a large drop which soaks up into the paper. This is then 
blotted by squeezing it between two pages of the book until the lustre 
is lost, and the reading is made at once before the drop becomes dry. 
In comparing the tints, position is of great importance. The observer, 
facing the sunlight, holds the book rather low before him, so that 
light is well reflected from the color-scale. A moist unstained ring 
around the drop is seen in anaemia. Leukaemic blood is poorly ab- 
sorbed, and has a color not agreeing with the scale. So great has 
been the demand for these books, following their recommendation in 
a very excellent text-book, that many editions have been published. 
There is now a slight reaction setting in against this scale. The per- 
sonal element enters in too largely, as two persons can differ widely 
in their opinion, and the trained eye sometimes even judges the tints 
of the scale, and reads without it. We hope the reaction will lead 
the practitioners to adopt some instrument requiring less guess-work. 

In hospital work we find it a great advantage to have several varieties of hae- 
moglobinometers in use, and to insist that the student shall use them all. Only 
in this way will he appreciate the strong and weak points of each. The man who 
uses but one soon places undue reliance upon its accuracy. Let him use two of 
different makes and get differences of from 5 to 10 per cent., and he appreciates 
the need of a standardized instrument. 

We have one, a new Miescher, which we reserve as the standard. When a 
clinical clerk signs for an instrument for ward work, he must first standardize 
the instrument against this Miescher, and in future work make the necessary cor- 
rection. Among our forty instruments of seven different types we find that the 
corrections necessary vary from 1 10 per cent., and are especially large in those 
over two or three years of age. 



THE BLOOD: HAEMOGLOBIN 



499 



These instruments very seldom read 100 per cent, in a normal person. From 
the records of 176 medical students, all normal men during the third decade of 
life, the readings made with great care, the Fleischl instruments in 161 cases read 
from 65 to no per cent.; 136 varied from 80 to 100 per cent., and 52 from 90 to 
95 per cent. ; the mean was 92.5 per cent. Of 156 records with the Dare instru- 
ment, varying from 65 to no per cent., the blood of 105 read from 90 to 100 
per cent. ; the mean 95 per cent. Of 150 students using the Gowers, the records 
varied from 70 to 120 per cent. ; 81 stood between 90 and 100 per cent. ; the 
mean about 92 per cent. Here the direct readings of the instruments not cor- 
rected with the Miescher are given. 

With the Miescher the blood of 125 students varied from 11.4 to 17.6 gms. 
per 100 cc. (The estimations were controlled for the most part by determinations 
at the same hour of the following day.) It is much harder or even impossible to 
state the mean, so uniform was the distribution. The average was about 14.5 gms. 
Considering this 100 per cent., the blood of 38 students varied from 90 to 100 
per cent., and 21 from 100 to 105 per cent. (Note how different the readings on 
the other instruments.) The variations with the Miescher seemed great, yet they 
ran more parallel to the blood-counts than did the others. (See page 501.) 

In conclusion, the Miescher is a laboratory instrument, and in 
clinical work is reserved for special cases; then it alone should be 
used. For the general run of cases without hematological interest, 
either the Sahli, Gowers, Dare, Oliver, or Fleischl is good enough, 
provided it be a standardized instrument, for it is the scale which is 
incorrect, and becomes more so with time. 

Jolles Ferrometer. — This method, proposed as the most accurate way of 
determining the amount of haemoglobin, determines the absolute amount of iron 
present in the blood. We shall merely outline the method. A small amount of 
blood is incinerated, the iron of the ash dissolved in a little acid potassium sul- 
phate, and the solution of iron then estimated colorimetrically by means of the 
ferrometer. In this apparatus the blood-iron solution is placed in one tube, in 
another tube a standard iron solution. The fluid from this latter tube is allowed to 
escape through a stopcock, drop by drop, until the tint of the two solutions is the 
same. For this method a small amount of blood, 0.05 cc, is all that is necessary. 
The incineration is done in a platinum crucible, the blood being first dried, then 
incinerated, the potassium sulphate, 0.1 gm., added, and the mixture carefully fused. 
After it is cooled the ash is then washed into the standard tube. The fluid in 
the tube used for comparison contains 0.5 mg. of iron and 0.1 gm. of the acid 
potassium sulphate per cubic millimetre. To each cylinder are then added 1 cc. 
of dilute hydrochloric acid (1 to 3 of water) and 4 cc. of ammonia sulphocyanide 
(7.5 gms. per litre). With the apparatus is a table giving the values in haemo- 
globin for the various readings. 

This instrument is not in use now, for various reasons. In the first place, the 
hsemoglobinometers are more accurate than they were at the time when this was 
used. In the second place, it was found that the results with this did not agree, 
well with those of the haemoglobinometers, and hence a different chemical composi- 
tion of the haemoglobin was assumed, or the presence of iron in the blood in other 
organic compounds. Even this was named " haematogen," or haematinogen. Both, 
of these arguments are rather lame, since haemoglobin is a rather constant body,, 
and in the very small amount of blood used the amount of iron in other forms: 
would hardly produce an appreciable error. Perhaps it is the method itself which, 
is at fault. The method has been severely criticised by Pekar, 36 who describes a 
Winkler method, another quantitative determination of the iron. 



Maly's Jahresbericht, vol. xxxiii. p. 241. 
30 



500 



CLINICAL DIAGNOSIS 



Rosin and Jellinek, 37 comparing the jolles instrument with a 
Miescher haemoglobinometer, find no fixed relation between haemo- 
globin and total iron. Some cases have high color, diminished iron, 
a variable count, as uncompensated heart disease. Some have high 
color, low iron, and' normal count, as jaundice, diabetes, Graves's dis- 
ease. Some have low color and high iron, as some anaemias and 
chlorosis. 38 

Haemoglobin. — One hundred cc. of normal blood are usually stated 
to contain from 13 to 14 gms. of haemoglobin. Careful estimations 
of the haemoglobin at the various ages have shown a regular age 
curve, quite parallel to that of the red blood-cells, but with variations 
a little more pronounced. 

Age. Gms. per 100 cc. of Blood. 

i to 4 days 19-329 to 21.160 

8 to 14 days 17.869 to 16.124 

8 to 20 weeks 15-362 to 12.92S 

6 months to 5 years 10.971 to 11.373 

5 to 15 years 11.151 to 11.796 

15 to 25 years 13-034 to 13-870 

25 to 45 years 14727 to 15.013 

45 to 60 years 12.484 to 13-150 

From this table of Leichtenstern (modified from Sahli's quota- 
tion) it is at once evident that the age curve must be considered in 
all blood-work, and the haemoglobin given in grammes per 100 cc. 
rather than in percentage, since there is no one figure which could 
be considered 100 per cent, for all ages. 

By oligochromcemia is meant a relative diminution in the amount 
of haemoglobin per unit volume of blood. It therefore is seen to have 
merely a relative and not an absolute value. 

By color index is meant the percentage of haemoglobin divided by 
the percentage of the red blood-cells. This figure, as Duncan first 
showed, is of considerable importance in some cases. For estimating 
the denominator, 5,000,000 red blood-corpuscles are considered 100 
per cent., while the numerator is the per cent, of haemoglobin read 
with any instrument. The color index is less than 1 in all cases in 
which the blood after anaemia is regenerating, hence in all secondary 
anaemias, and especially in chlorosis, in which the average is about 
0.5, in some cases being as low as 0.3. In pernicious anaemia, on the 
other hand, the index is increased, the average in a large number 
of cases of Cabot being 1.04, and one case reaching 1.75 (count 1,000,- 
000, haemoglobin 35). The high color index is of especial value in 
differentiating pernicious anaemia from certain cases of cancer of the 
stomach, a diagnosis clinically hard to make. To be of value, how- 

37 Zeits. f. klin. Med., Bd. 39, p. 109. 

38 See also Mayer, Zeit. f. klin. Med., 1903, vol. xlix. p. 475. 



THE BLOOD: HAEMOGLOBIN 



501 



ever, the variations must not be in the second decimal place. It is 
not a strict mathematical calculation ; the figures are too approximate 
for that. 

The question arises at once, What is the color index reckoned in the above 
manner for the average normal man and woman ? Five million is only in very 
general terms the normal figure, and few haemoglobinometers read normal blood 
at ioo per cent. As stated on page 499> taking instruments as they come, the index 
in fairly normal persons varies from 0.80 to 0.88. In the case of our students, 
the men, with the Fleischl and Gowers instruments had an index of 0.84, with the 
Dare, 0.87; the women, with the Fleischl, 0.88, Dare, 0.9, Gowers, 0.82. Yet we 
often see cases with the above indexes reported as " mild chlorotic anaemia." All 
our cases are to be judged in the future with this normal index in view. 

The question was approached in still another way. Our students' work included 
fifty-three records of counts and Miescher haemoglobin estimations made on the 
same bloods at the same hour. The counts varied from 4,600,000 to 6,700,000, and 
the haemoglobin from 10.9 to 17.2 gms. If in each case the number of grammes 
of haemoglobin per 1,000,000 cells be reckoned, the mean of these figures should 
be an approximately normal color-index. ' These quotients fell within surpris- 
ingly close limits, 42 of the 53 varying from 2.2 to 2.8 gms. ; mean, 2.63 gms. 
per 1,000,000 cells. Using this figure as the standard of haemoglobin content, we 
hope in the future to be more accurate in our use of the color index. 

One point we may be pardoned if we emphasize. Students seem to consider 
that the mechanism regulating the blood-count is almost as delicate as that con- 
trolling the body heat, and that the count of the blood of normal men should vary 
almost as little as does the temperature, although that varies somewhat. The 
more carefully the counts are made, the better the instruments used for haemo- 
globin, the more evident are the individual, both general and local, the daily and 
seasonal, and the racial, variations. It is more like the height, weight, or muscular 
development. And yet the regulation of the composition of the blood is wonderful. 
It varies within quite narrow limits, although through the vessels pass enormous 
amounts of water as in diabetes insipidus, of water and solids as in diabetes 
mellitus, of albumin and water, as is seen in cases of rapidly collecting ascites 
repeatedly tapped with the frequent withdrawal of even 8 litres of what is prac- 
tically blood-plasma, while the blood remains wonderfully little changed. Yet no one 
figure is normal for all men, nor constantly for one man. The same is true of the 
total amount of haemoglobin per 100 cc, and also for that per cell. Hence, in 
judging of blood reports one must not try to apply any hard or fast rules, but to 
study these variations, since they may be put to practical use. 

The " volume index" or the quotient of the volume per cent, and 
the count per cent. (5,000,000=100 per cent.) promises well. 39 To 
determine the volume of the corpuscles Capps uses the hematocrit 
and undiluted blood. A length of the column of corpuscles of 50 
per cent, he accepts as normal, hence the 100 per cent, of the calcula- 
tion (see page 449)- 

The most important result he obtained is that in pernicious anaemia 
the color index never exceeds the volume index; that is, that 
there is no supersaturation of corpuscles with haemoglobin, and the 
high color index is due to increase of size alone. Yet on the other 
hand, in other anaemias the color index may fall below the volume 
index, and the color index drops more rapidly than the volume, while 



39 Capps, Jour, of Med. Research, 1903, vol. v. 



502 



CLINICAL DIAGNOSIS 



during regeneration the volume returns to normal first. He has never 

seen any evidence of " acute dropsy" of the cells. 

WHITE BLOOD-CELLS 

Granulations of Leucocytes — By granules are here meant the minute 
bodies, usually spherical, of a size and staining character fairly con- 
stant for each granulation, which seem to be not accidental but to 
belong to the protoplasm ; they are perhaps the product of the secre- 
tory activity of the cell, but not in the sense that all protoplasm is 
slightly and indefinitely granular; they are definite inclusions in the 
cell protoplasm, and are liberated as independent bodies which swim 
free in the plasma when the cell breaks up. From them can per- 
haps be distinguished degeneration of protoplasm, accumulations of 
products of metabolism, and inclusions from phagocytosis. 

The various granulations as classified by Ehrlich are, Eosin- 
ophilic, acidophilic, or oxyphilic (a). These granules are 
coarse, about i micron in diameter, spherical or slightly oval, quite 
uniform in size and color, are very refractive and so in the fresh 
specimen appear black. From a mixture of stains these will always 
take the acid ingredient. These granules have been found in the blood 
of every animal whose blood has been examined, from the frog to 
man. They are of albuminous nature and not fatty as their appear- 
ance would indicate. Barker has found that they contain iron. 

Amphophilic (/?). — These granules are said to vary in size, 
some to be as large as a granules, others considerably smaller. Some 
are said to take acid and others basic dyes. They stain like the 
eosinophilic granules, except that in a mixture of eosin and indulin 
they will take the latter; they also take certain basic stains. They 
occur often in the same cell as the a granules, hence Ehrlich considers 
them a younger stage of these, and this to be the only case in which 
two specific granulations are found in one cell. They are found in 
some leucocytes of the bone-marrow of man and various animals 
(rabbit and guinea-pig), and in the peripheral blood in certain 
anaemias. These may explain, in leukaemia for instance, the varia- 
tions in the size and tint of the granules in some of the eosinophile 
cells. A few may be present in an eosinophile cell. 

Basophilic and Mastzell Granules (y). — In the connective 
tissue and blood of all animals and man are cells which contain large 
basophile granules. Those of the tissues stain -best with dahlia, taking 
a metachromatic tone rather than strictly basophilic, resembling that 
of mucin, of which, indeed, some claim that they are composed. This 
tone is best seen if polychrome methylene blue be used, and is explained 
as due to the methylene azure of this stain. The granules are spherical 
or oval in shape, and vary considerably in size in the same cell. Cells 



THE BLOOD: LEUCOCYTES 



503 



containing - somewhat similar granules occur to a small per cent, in 
normal blood, and are increased in leukaemia, while in some cases of 
pleural exudate and of gonorrhoea this may be the chief granulation 
of the leucocytes of the pus. Considerable doubt exists, and is ad- 
mitted even by Ehrlich, concerning a relationship between the baso- 
phile cells of the blood and of the tissues, the latter the true Mast- 
zellen. Their origin seems different. In fact, their only resemblance 
seems to be that both have basophile granules, yet which do not stain 
exactly alike. What is more, considerable doubt exists whether the y 
granules in cells of abnormal blood are exactly the same as those pres- 
ent in the normal blood and bone-marrow, since even between these 
certain variations in the staining qualities exist, and those in leukaemic 
blood are more soluble in aqueous solutions than those of normal 
blood. It is, therefore, at least possible that we have here to do not 
with one specific granulation, but with three or more different granu- 
lations, or with the same granulation at different stages of its develop- 
ment. 

Basophile Granulations (8). — These granules were originally 
described by Ehrlich as occurring in the mononuclear cells, especially 
the lymphocytes ; as not staining by dahlia, and hence differed from y 
granules ; and occurring especially in the cells of bone-marrow. Ehr- 
lich, while he has not publicly repudiated these, leads one to suppose 
that he now considers them to be not true granules, but nodes of the 
reticulum of the protoplasm. 

Neutrophile Granules ( £ ) . — While a somewhat similar 
granulation occurs in some animals, cattle, swine, and sheep (Hirsch- 
feld), neutrophile granules of this size, arrangement, and color are 
found only in man, and hence are considered by Ehrlich specific for 
him. They are extremely fine, dust-like, and occur in the mononu- 
clear cells of the bone-marrow, a few in transitional cells, and fill the 
ordinary finely granular cells of the blood. With the Ehrlich triple 
stain they take a lilac color, and this is really the only specific stain 
for them, but they also will take an acid stain; hence others name 
them the " fine oxyphilic granulation," in contradistinction to the 
eosinophilic or " coarsely oxyphilic." 

Neusser's Perinuclear Granulation. — In certain leucocytes, 
mononuclears especially, and polymorphonuclears, but in some speci- 
mens stained with Ehrlich triple stain in any of the leucocytes, are 
sometimes seen blackish-green granules, which always appear attached 
to the nucleus. Their size varies much, and they have often a glisten- 
ing or refractile appearance. Neusser considered them as character- 
istic of the uric acid diathesis. It has been shown since then 40 that 
these are in reality artefacts which can be produced by variations in 
40 Futcher, Centralbl. f. innere Med., 1899. 



504 



CLIXICAL DIAGNOSIS 



heating and in the stain, and, indeed, with some mixtures may be 
produced at will, and which bear no relation to the output of alloxuric 
bodies in the urine. 

The Granulation of Lymphocytes. — In well-spread specimens 
stained by the various modifications of the Romanowski stain are seen 
fine violet granules in about one-third of the lymphocytes, especially 
those with a fairly wide protoplasmic margin. They are not always 
spherical; their size is between the <* and e; few or many may be 
present in one cell, yet, as a rule, they are not too numerous to count. 
They occur also in the large mononuclears and transitionals. They 
cannot be stained by the Ehrlich stain. By this discovery Michaelis 
and Wolff 41 consider that they have broken down the sharp line of 
demarcation drawn by Ehrlich between the granular and the non- 
granular cells. They are not found in cells from smears of lymph- 
glands, or of marrow. Ehrlich replied that while it cannot be denied 
that these were granules, yet they cannot be considered as forming a 
definite granulation in the sense in which he used the term, since they 
varied so in number in the type of cells containing them; nor did 
they occur in all the cells of the class in which some were found; 
and they required a very special method of staining to demonstrate 
them. 

Fatty granules occur in the leucocytes in cases of hyperpyrexia, 
are easily recognized and easily stained with Sudan III. 

Ehrlich's classification of granules is exceedingly satisfactory as a text-book 
description, but one working much with the blood finds that nature has not drawn 
the lines so sharply. Ehrlich admits that both a and e granules develop from 
basophile granules. In eosinophile cells there may be a and P granules ; apart 
from this possibility, all a granules are not of the same size, but some larger ones 
are mixed in, especially in the cells of bone-marrow, sometimes a few in one 
eosinophile, sometimes many. These may resemble myelin or other degenerations 
or cell inclusions, and, indeed, the larger or most may be, but excluding these, 
even in well-stained specimens the size is not always uniform. The view is to 
be mentioned that all eosinophile granules are the results of phagocytosis of frag- 
ments of red cells, or of platelets. Of the y granules, at least two varieties exist 
and perhaps three. Cells with various sizes of e granules occur, and artists 
employed to illustrate articles on blood absolutely refuse to picture them all of 
the same size. Again, the line between the a and the e granules is not always 
sharp. It may be an individual peculiarity, but in the blood of some patients occurs 
a large group of cells with acidophilic granules, which one hesitates to classify 
as neutrophile cells, since they are so large, or as eosinophiles, than which granules 
they are slightly smaller. This is true in fresh preparations as well as in the 
stained specimens, and has been admitted by several observers, especially in cases 
of trichinosis, hence some consider them transitionals (Brown, McCrae, Anderson). 
And, lastly, especially in smears of the bone-marrow and leukaemic blood, the line 
between the granular and non-granular cells is exceedingly difficult to draw, 
since there are so man}' mononuclear cells with a protoplasm suggesting a faint 
granulation. 

"Virch. Arch, Bd. 167, p. 151. 



THE BLOOD : LEUCOCYTES 



505 



We do not overlook the fact that much depends on technic. Of a set of smears 
made from the same patient at the same time, but heated and stained with 
slightly different technic, the granules will appear of somewhat different size 
and of markedly different color-tone. It is with due allowance made for this that 
we make the above statements. 

Leucocytes. — We give, first, Ehr lick's classification, since that is 
the one in common use. 

Lymphocytes (Plate L, i, also 3 and 4). — These cells are 
smaller (5 to 8 microns in diameter) or larger (8 to 10 microns) 
than the red blood-cells. The nuclei are relatively large, round, 
quite deeply stained, centrally placed as a rule, and have one or 
two nucleoli. They may be deeply notched, especially the smaller 
ones, and even suggest a polymorphonuclear cell, but are never just 
like it. Often there is a clear band between nucleus and protoplasm. 
The protoplasm forms a narrow rim around the nucleus, is some- 
times acidophilic (older cells?), but generally basophilic, often more 
so than the nucleus, and takes a grayish-green stain with the triple 
stain. Of other cells the nucleus seems naked. The larger cells of 
this group have an irregularly staining nucleus with a chromatin net- 
work and a faintly granular margin of protoplasm. These latter 
forms may be exceedingly large in lymphatic leukaemia and in the 
blood of normal infants. It is rare to see them in other conditions. 
These cells, if stained with the polychrome methylene blue-eosin 
stains, show a distinct granulation in about one-half their number. 

The lymphocytes constitute from 22 to 25 per cent, of the leuco- 
cytes in the normal adult blood, and from 40 to 60 per cent, in the 
infant's. 

Large Mononuclears. — By " mononuclear" is meant that the 
nucleus is round or lobulated but not polymorphous. These cells are 
two or three times as large as red blood-cells, have a large, oval, 
vesicular, eccentrically placed, faintly staining nucleus, which indeed 
may be overlooked, and abundant weakly basophilic protoplasm with- 
out granules (Ehrlich stain). Nodal thickenings are present, and by 
Nocht stain some show a granulation. These cells constitute about 
1 per cent, of the leucocytes of the normal adult blood. While in 
normal blood these cells are practically all large, in other conditions, 
especially typhoid fever and malaria, this group may be represented 
by all sizes from that of lymphocytes to large giant-cells. The small 
forms it is easy to distinguish from lymphocytes, but they occur very 
seldom in normal blood. (Plate II. The group 9-20 contains many. ) 

Transitional Cells (Plate I., 5). — These cells resemble the 
large mononuclears, but are often larger, — in fact, the largest cell of 
the blood. The nucleus is much notched, giving the so-called " wallet" 
or " saddle-bag" nucleus. The protoplasm stains quite deeply in Ehr- 



506 



CLINICAL DIAGNOSIS 



lich's stain, and often presents a very few neutrophile granules. These 
constitute from i to 3 per cent, of the leucocytes of the normal adult. 

Polymorphonuclear Neutrophiles (Plate L, 6, 7). — These 
cells, which constitute from 70 to 72 per cent, of the leucocytes of the 
adult and from 18 to 40 per cent, of the child's, are somewhat smaller 
than the transitional cells. When spherical they are about 10 microns 
in diameter, but in a well-spread smear, in which they have flattened 
out upon the glass, they may seem about twice this size. The amount 
which they have flattened explains their varying size, so often decep- 
tive in smears of unequal thickness. The nucleus is characterized by 
its polymorphous nature and its deep stain, due in many cells to 
pycnosis. It may be a strand variously bent, or small fragments, two 
or more in number, connected by fine filaments. The protoplasm takes 
a faint acid stain. It is well filled with the neutrophile granules which 
may cover the nucleus. When migrated these are the ordinary pus- 
cells. They contain glycogen in certain conditions. 

Eosinophiles (Plate I., 2). — These cells are of the same size or 
perhaps a little larger than the preceding. The nuclei may have the 
same shape, yet less pycnotic, fainter staining ones are the rule. The 
protoplasm is often slightly more abundant, and is filled with eosino- 
philic granules, which do not often lie upon the nucleus. These cells 
constitute from 2 to 4 per cent, of the normal leucocyte count. 

Mastzellen (Plate L, 8). — This name is given, perhaps incor- 
rectly, to any cell with basophilic granules. It is not at all certain 
that these are in any way related to true Mastzellen of the connective 
tissues. These cells are about the same size as the preceding, but more 
often smaller. The nucleus, is polymorphous, very faintly staining, 
often trilobed. The protoplasm contains a variable number of gran- 
ules of different sizes, yet for the most part as large as a granules, 
which form a band around the nucleus. These granules are not stained 
by the triple stain, hence one sees only the spaces occupied by them. 
(These are probably the reticulated or vacuolated cells of Uskow.) 
They stain best in thionin and are said to take a metachromatic tone. 
These cells constitute about 0.5 per cent, of the total count. They 
have every appearance of old cells : are small, do not spread well, but 
look shrivelled, with acidophilic protoplasm and polymorphous nucleus. 

The leucocytes found in pathological conditions are: 

Myelocytes (Plate I., 9, 11, 14, 17).— While any cell of bone- 
marrow is, strictly speaking, a myelocyte, by this term is generally 
meant one with a round nucleus and granular protoplasm. Neu- 
trophilic and eosinophilic myelocytes occur. Their size varies from 
that of the large mononuclears to that of red corpuscles. The largest 
and smallest neutrophile myelocytes are found in the blood only in 



PLATE II. 



A, B, and C are groups of cells from three cases of Acute Lymphatic Leukaemia. 

A. Cells from a case of the large-celled variety. 

B. Cells from a case of the small-celled variety. 

C. In this case the cells were almost achromatophilic, with the protoplasm slightly acidophilic. 

Leucocytes from Normal Blood and Malaria (in which condition is a large number of large 
mononuclear nongranular forms). 
9, 10, 13, 19. Large mononuclear cells. 

11. A giant mononuclear cell. 

12. A mononuclear cell with the Wolff-Pappenheim granules. 

14. An eosinophile leucocyte. 

15. A naked nucleus. 

16, 17. Small mononuclear cells. 
18. Mastzell. 

20. A neutrophile leucocyte. 

21. Trypanosoma gambiense. 

22, 24, 25. Red cells with Grawitz's basophile granulation. 
23. A blood platelet. 



PLATE II. 




TRYPANOSOMA GAMBIENSE, 
FROM A CASE OF "SLEEPING SICKNESS. 
STAINED WITH HASTING'S MODIFICATION OF 
ROMANOWSKI'S STAIN. ALL DRAWN TO SAME SCALE. 



BASOPHILE GRANULES 
OF RED BLOOD CELLS. 



F. S. Lockwood. 



THE BLOOD: LEUCOCYTES 



507 



myelogenous leukaemia, but a few the size of the granular leucocytes 
may be found in any condition with a high leucocyte count. The char- 
acteristic point is the shape of the nucleus, which is either perfectly 
round, oval, indented or kidney-shaped, but never polymorphous or 
pycnotic; if it were, the cell would count as an ordinary leucocyte. 
It is usually centrally placed. It is impossible to draw a sharp line 
between a myelocyte and polymorphonuclear cell (Plate L, 12, 13), 
since every possible gradation occurs. But one soon forms a standard 
for himself. As myelocytes we count all cells w^ith round, oval, or 
kidney-shaped nuclei, providing the nucleus occupies at least one-half 
of the cell. Such a nucleus will not be stained diffusely by any good 
nuclear dye. A cell with nucleus more compact, more distorted, or 
more diffusely stained than this ranks as a leucocyte. The specifica- 
tion " round or oval nucleus " needs a further qualification, for one 
sometimes sees such nuclei in leucocytes. But in leucocytes they are 
relatively small (occupying only about a quarter of the diameter of 
the cell) and stain diffusely. One is tempted to believe that could 
he get a side-view of them, they would be polymorphous. Their lack 
of chromatin net-work also is enough to prove them leucocytes. For 
the question of the motility of myelocytes, and most now agree they 
are motile, see the writings of Wolff. 42 

Some myelocytes are full of granules, some have but few, and 
they are scattered. The very large forms occur in the bone-marrow 
and in well-made specimens of the blood of myelogenous leukaemia, 
but of the most of them only a large faint nucleus and granules free 
in the plasma are seen. Some have a large nucleus and a narrow 
rim of protoplasm, others a smaller nucleus and more protoplasm. 
Still others are very small. 

Eosinophile Myelocytes (Plate I., 14). — These are the exact 
analogue of the preceding, and occur in much the same conditions, 
but less often and in much smaller numbers. They are found espe- 
cially in splenomyelogenous leukaemia and in anaemia pseudolym- 
phatica infantum. 

Small Neutrophiles ; Pseudolymphocytes. — These cells have a round, in- 
tensely staining nucleus and a narrow margin of protoplasm full of neutrophil 
granules. Their size is about that of a lymphocyte. They are rare, occurring 
especially in pleuritic exudates, and are supposed to arise from fragmentation of 
the polymorphonuclear cells. 

Irritation Forms. — The description given of these cells is the following: 
They vary in size from a lymphocyte to a large mononuclear, but resemble the 
former more; the nucleus is round, of a bluish-green color (Ehrlich stain), often 
eccentric and without a chromatin net-work; the protoplasm stains an intense 
rich brown; these have no granules. Turk considers that they have the same 
occurrence and meaning as myelocytes. 

42 Deut. med. Wochenschr., March 5, 1903. 



508 



CLINICAL DIAGNOSIS 



Uskow's Classification. — This writer has given a classification of leucocytes 
based on specimens stained with the triple stain, more objective than that of 
Ehrlich, and although not in common use, yet valuable to bear in mind when 
using any classification. 

A. Lymphocytes. — Cells with a round nucleus, narrow ring-like rim of proto- 
plasm separated from the nucleus by a clear sharp circle, the nucleus and proto- 
plasm staining intensely. 

(1) Small Lymphocytes. — The size of red blood-cells or smaller, with a uni- 
form ring of protoplasm. 

(2) Lymphocytes. — A little larger than red blood-cells, the rim of proto- 
plasm often thicker on one side, giving the seal-ring appearance, or with two 
or three prominences. 

B. Transparent Corpuscles. — Characterized by the quantity of protoplasm which 
with the triple stain remains colorless. The nucleus is homogeneous, round, oval, 
or bean-shaped, usually eccentric and stains a feeble pinkish shade. 

(3) Small transparents, size of large lymphocytes, or a little larger, often in 
the form of a square with rounded, corners. 

(4) Large, three to five times that of a red cell ; the nucleus eccentric. 

(5) Lobulated Forms. — These are the largest cells of the blood. The nucleus 
is on one side, usually toward the centre of the corpuscle, with one or two deep 
indentations. 

C. Transitional Cells. — These have many of the characteristics of lymphocytes 
and transparents. They are rich in a protoplasm which is sometimes slightly 
granular and always takes a good stain, but less intensely than that of lymphocytes. 
The nucleus stains more deeply than the protoplasm and usually has no clear 
ring around it. 

(6) Small Transitionals. — Resemble giant lymphocytes or colored small trans- 
parents. 

(7) Transitionals, are larger. 

(8) Lobulated forms, the largest of this group. 

D. P olymorphonuclears. — The nucleus intensely staining and of various shapes. 
Protoplasm abundant, coarsely or finely granular. 

(9) With thick, rod-like nucleus, which stains rather feebly. Granules smaller 
than those of the other neutrophiles. 

(10) Nucleus like a bent rod, often twisted at one end. 

(11) Multinuclear, the fragments, however, connected by strands of chromatin. 
Uskow considered the above classification based on age. As young forms, he 

considered the small and large lymphocytes and the small transparents ; the ripe 
elements were all the transitionals and the large and the lobulated transparents, 
while the over-ripe forms have polymorphous nuclei. The classification is based 
on Ehrlich's stain, and hence cannot, as a whole, be as well applied to specimens 
otherwise stained. It is, however objective, and gives a much better descrip- 
tion of the cells actually found than does the Ehrlich. 

Differential Counting. — For a differential count a satisfactory classi- 
fication is a necessity. Since we know so little of the relationship 
between the various leucocytes, of their age, their changes, their origin, 
and of their function, the only classification possible would be a purely 
morphological one. Pappenheim has proposed such a one, but his is 
too complicated for clinical use, hence Ehrlich's, being the simplest, 
still obtains. Ehrlich separates in the normal blood, small mononu- 
clears, large mononuclears, transitionals, polymorphonuclear neu- 
trophiles, eosinophiles, and Mastzellen. 

By small mononuclear is meant any non-granular cell smaller than 
a polymorphonuclear neutrophile. This group would include, there- 



THE BLOOD: LEUCOCYTES 



509 



fore, all lymphocytes and the small transitionals and transparents of 
Uskow. As large mononuclears are classified any non-granular cells 
larger than a polymorphonuclear neutrophile, with a round or oval 
nucleus; any cell within the same size limits, but with an indented 
nucleus, is called a transitional. The polymorphonuclears, both neu- 
trophiles and eosinophiles, are clear enough. As a Mastzell, is counted 
any polymorphonuclear cell without granules (Ehrlich's stain), or 
with blue granules if methylene blue is used. 

For normal blood this classification is satisfactory, but for pathological con- 
ditions many objections arise. While the lymphocytes seem to form one distinct 
class (Plate I., 3, 4, 15, 20), the other mononuclear cells it is impossible to 
classify on the staining character of their protoplasm, but this point is quite certain, 
the group of large mononuclears has large, medium, and small forms, and any 
line dividing this group is purely arbitrary; it increases the number of the 
lymphocytes by cells which do not belong there, and diminishes a group which 
should not be divided. This is best seen in typhoid fever and malaria, in which 
diseases the group of the transparent cells of Uskow is increased as a whole, 
both the large and small forms : and in the so-called lymphatic leukaemia, in many 
cases of which the mononuclear cells are certainly not lymphocytes. 

Neither is it just to separate groups on the basis of an indentation of the 
nucleus. Ehrlich's name " transitional" still exists, but as soon as, by means of 
the triple stain, he discovered the myelocyte, he saw at once that the transitionals 
were no longer necessarily a step in the development of a polymorphonuclear cell. 
It is now generally agreed that these large cells with indented nuclei are only 
older (senile) forms of those with oval nuclei, and need no longer be counted as 
separate. As regards the transparents and transitionals of Uskow, it may well 
be, as some suggest, that the younger cells have a more basophilic protoplasm, 
while the older cells have an acidophilic ; or these cells may be of really distinct 
origin. 

The line between myelocyte and leucocyte is very hard to draw, since no line 
can exist in an unbroken series of intermediate forms. 

In leukaemia to draw a line between large mononuclears (Plate I, 16, 19, 21) 
with deep staining protoplasm and granular myelocytes is also very hard, since 
perhaps here also no line exists ; yet in well stained specimens one is in doubt 
concerning but few cells. 

One group of cells does confuse us, especially in heated specimens, cells which 
are represented merely by a faintly staining nucleus, and that this is a nucleus 
one is often in doubt ; especially if one control his count by one on the fresh 
blood, then he is sure all are not leucocytes. Such cells should not be passed 
over, but counted as " undetermined cells," for only in that way will the percentage 
of those groups which are more resistant be fairly correct. These undetermined 
cells are almost all large mononuclears, yet if many are found on preliminary 
examination of a smear, that smear should not be used for a differential count. 

To differentiate eosinophiles and neutrophiles there should be little difficulty 
in a well-stained specimen, and yet in certain cases the question is very hard, and 
one doubts for that case the specificity of granules. We believe that most observers 
do not pay much attention to a point formerly emphasized, the characteristic lilac 
tint of the neutrophile granules ; that they do not believe that true eosinophile 
granules may be as fine as neutrophiles and distinguished by their color-tone alone, 
as do some who have written concerning eosinophilia. To most of us neutrophile 
granules are fine and eosinophile coarse, and little attention is paid to their color 
except as a basis to criticise the staining mixture used. One further point is im- 
portant. It is customary to count neutrophile myelocytes in a class by themselves, 
but eosinophile myelocytes with the eosinophile leucocytes. We are not at all sure 
this is a fair method. 



510 



CLINICAL DIAGNOSIS 



For our differential counts we use specimens stained with Ehrlich's 
triple stain, and separate first the granular and non-granular cells. 
Of the latter the lymphocytes might be counted alone, and all other 
mononuclear non-granulars in one group, unless they be increased, 
when one could separate transparents and transitionals (Uskow) on 
the basis of the protoplasmic stain, or large mononuclears and transi- 
tionals ( Ehrlich ) on the basis of the shape of the nucleus. Yet in 
routine ward work and for the sake of uniformity we still separate 
small and large mononuclears, using the polymorphonuclear neutro- 
phile as the size-line, but count large mononuclears and transitionals 
together. The granular cells are divided as neutrophils, eosinophils, 
and basophiles. Separate classes are made for £ myelocytes and a 
myelocytes. Nucleated reds are also counted and calculated as " num- 
ber per thousand leucocytes.'' 

The list of cells is. therefore, the following, using the customary 
abbreviations: S. monos., or s.m. ; 1. monos., or l.m. ; tr. ; pmn. e, 
or pmn. n. : pmn. a, or pmn. eos. ; Mastz., myeloc. e, myeloc. a, 
nucleated reds, normobl.. intermed., megalobl. 

For a differential count a mechanical stage should be used, and at 
least five hundred, better one thousand, leucocytes counted. Yet one 
can get a fair idea of a slide without a mechanical stage. Some keep 
count with a pencil on a paper ruled into columns for each group ; 
others use a slide-box divided into compartments by slides., into which 
he drops beans, one bean for a cell. Since one starts always with 
five hundred or a thousand beans, the mathematics of this calculation 
are easy. 

Many use specimens stained with the various polychrome methy- 
lene blue-eosin stains for differential counting, with confidence of their 
ability to distinguish the various granulated cells, and the added ad- 
vantage of better-stained nuclei and stained basophilic granules. In 
ordinary use this is very well (Plates IT. III.). The average Ehr- 
lich triple stain mixture in use is a poor fluid, and gives a poorer 
picture than these. Ehrlich's neutrophilic granulation has not gained 
quite the clinical importance which he expected, but it is only fair 
by Ehrlich to use the term " finely granular cells" or " fine acid- 
ophilic." in case other stains are used, and reserve the term neu- 
trophilic in connection with his triple stain, for although the color- 
tone of the two granulations is different when the former stains are 
used, the result is not so specifically neutrophile,. as with the triple stain. 

With these stains (Nocht and its modifications) all nuclei stain 
much better than with the Ehrlich. The protoplasm also stains much 
better, an intense blue with very beautiful net- work, or a diffuse 
blue, or a red. The finely granular cells present a diffuse haze of 
purplish granules, and many of them can be made out easily and. 



THE BLOOD: BONE-MAKJROW 



511 



clearly and their tint seen, but the picture is not so beautiful as in an 
Ehrlich specimen. The eosinophile granules take the eosin. For very 
careful work it is advisable to count two specimens, one stained with 
Ehrlich's triple stain for granules, one with hsematoxylin-eosin for 
nuclei; by comparison these will correct each other. 

We hope that soon much more differential counting will be done 
with fresh blood preparations. It is rather hard and often incon- 
venient, but perhaps more accurate than with stained smears, since 
what one loses in the tint he gains by avoiding artefacts and broken- 
down cells. 

Bone- Marrow. — The study of the bone-marrow is a subject of 
primary importance. In it are found practically every cell which 
occurs in the blood in almost every condition ; that is, a large number 
of those cells which are unusual in the peripheral blood, and a com- 
plete series of transitional forms between different groups ; hence this 
study renders the blood-pictures more intelligible. 

The study of fresh marrow is especially important ; that of the ribs 
of young babies, especially of those born prematurely, is best. Frag- 
ments removed in operations for empyema are excellent, and autopsy 
specimens if fresh enough. It is surprising how quickly some of the 
interesting mononuclear forms, " young" cells, disintegrate. The 
large form of myelocytes also soon disappear, and in leukaemia the 
marrow may soon be of very little value, showing only a confused 
mass of nuclei in a cloud of free granules. A small piece is squeezed 
in a pair of forceps and a small drop of the exuding marrow picked 
up on a cover-glass and at once pressed down onto a slide. Spicules 
of bone must be avoided. Very rapid work is necessary, since the drop 
dries very rapidly. The marrow may be diluted with salt solution 
if desired. For stained specimens, the stroke method is the most 
useful; that is, the marrow is smeared in lines on the cover-glass 
by drawing this across the end of the bone. The specimen is allowed 
to dry in the air and then may be fixed and stained just as blood 
smears. If the marrow is fatty the smears do not turn out well. If, 
fixed by heat, it is well to remember that it is easier to underheat 
than it is to overheat, and the easiest method is to place the cover- 
glass on the copper plate, smear up, at the spheroidal point (that is, 
the point at which the drop of water does not boil but merely rolls 
off the plate) for forty-five or more seconds. Such specimens will 
for the most part have good areas for study, especially at the edges 
of the thick portions, and a few such fields are all that is desired. 
Specimens made thin, in the hope that the surface will be uniformly 
good, are usually failures, for those too thick are better than those 
too thin if heat and the Ehrlich stain be used. 

Bone-marrow varies much. In some places will be found nests 



512 



CLINICAL DIAGNOSIS 



of nucleated reds in enormous numbers ; in other places nests of 
leucocytes, myelocytes, and of intermediate forms. Different parts of 
the same rib vary, as we have found to be markedly the case in infant 
marrow, Since the marrow in different bones and in different parts 
of the same bone varies so, it is impossible from a limited search to 
say what is the general medullary condition of that case (Grawitz), 
and this may explain the lack of evident relation between a marrow 
and a blood picture. 

While it is impossible to really count the cells of the marrow, yet 
differential counts can be made of those found in measured areas. 

Nucleated Red Blood-Cells. — The term " erythroblast" is used 
by some to mean a nucleated red blood-cell ; by others a colorless 
ancestor form of these. YVe use it for any nucleated red cell. 

(i) Normoblasts, (a) Howell's Mature Nucleated Reds ( Plate 
I., 29). — These are the color of the non-nucleated red blood-cor- 
puscles, with a pycnotic nucleus 3 microns or slightly less in diameter, 
sharply defined, without a chromatin net-work, dense, homogeneous, 
structureless (triple stain), of a dense uniform blackish-green color, 
often vacuolated, hence in the nucleus is often a bright spot in the 
fresh and an unstained area in the stained specimen. These nuclei 
are so characteristic that they may be recognized even if not sur- 
rounded by protoplasm. They often present amitotic figures, giving 
rise to rosette forms of two to four or even twelve fragments. Some- 
times these fragments are all connected by strands of chromatin (see 
Plate L, 34, Fig. 113, c) . This nucleus is often surrounded by a clear 
zone which probably represents space left between the contracting pro- 
toplasm and nucleus. The nucleus rnay not occupy this space, but rest 
upon a margin of the red cell or even at some distance from it. This 
is explained by Ehrlich by the weight of the nucleus — when the 
specimen is made the cells are violently thrown into a new position, 
which centrifugal force throws the nucleus out of the cell. And yet 
this will not explain all free nuclei, since they are seen in specimens 
made in various ways and in sections as well. Pappenheim and 
Israel claim that in leukaemia especially such free nuclei result from 
the degeneration of the surrounding protoplasm. 

From these cells with very pycnotic nuclei, in which can be seen 
no structure whatever, are all gradations with the chromatin structure 
more and more evident till we reach (b) Howell's immature nucle- 
ated reds ( Plate I., 30, Fig. 113, (7). These are of a little larger size 
than an ordinary red blood-cell with color perhaps a little paler ; the 
nucleus is slightly larger, with the chromatin fibres radially arranged 
( in leucocytes it forms a meshwork [Pappenheim] ), while clearly seen 
mitotic figures are not rare. Division of these cells is rapid, requiring 
but fifteen minutes. In the bone-marrow this is the dominant red cell. 




Fig. 113. — Nucleated reds from the blood of a foetus 15 cm. long, a, mature nucleated red ; b, inter- 
mediate form and rosette; c, mature red, nucleus fragmented; d, free nucleus of a mature red; 
mature red, polychromatophilic cell ; f, polychromatophilic megaloblast. 



THE BONE-MARROW 



513 



These two forms are generally called normoblasts, although the 
larger immature forms are by some classed as intermediates. They 
are the precursors of the ordinary non-nucleated red blood-cell, but 
do not reach the circulation of a normal adult except as an anomaly. 
Their appearance in the general circulation indicates an increased 
activity of the bone-marrow, such as occurs after hemorrhage. They 
appear in the blood of a child more readily than in that of an adult. 
Many occur in pernicious anaemia, more in splenomyelogenous leu- 
kaemia, and some in post-hemorrhagic anaemias. As in the marrow 
so in the blood these cells occur in groups often, and lie free from the 
rouleaux (since heavier than the others?). 

These cells are " orthochromatic" normally; that is, they stain 
like the ordinary non-nucleated reds (oxyphilic). There is a group of 
fuchsinophilic cells which some consider young forms, but which 
Engle considers a distinct group; other cells, especially in pernicious 
anaemia, are polychromatophilic. 

" Blood crises" is the term given by v. Noorden to the periods, 
usually in the convalescence of an anaemia, during which for a few days 
enormous numbers of nucleated reds and a leucocytosis will be found, 
and this followed by a jump in the red blood-count. The nucle- 
ated reds then disappear and the increase in the count is less rapid 
until perhaps another crisis occurs. V. Noorden reported cases with 
gains of half a million cells in four days. Since a leucocytosis is also 
present, he considered it a transitory increase of activity on the part 
of the bone-marrow to regenerate the blood. Normoblasts are, how- 
ever, not the only red cells increased, and a crisis is not always a sign 
of improvement (see page 568). It is to be distinctly emphasized 
that the number of nucleated reds in the circulating blood is a poor 
index of the activity of the bone-marrow, much less so is the actual 
count of red cells. The bone-marrow may be able to maintain the 
count at the normal level through the most strenuous efforts. 

Intermediate Red Blood-Cells (Plate I., 31). — This is an 
exceedingly indefinite term ; by it are meant cells which are not 
quite large enough to be called megaloblasts, and yet are larger than 
normoblasts ; large cells with the nucleus of an immature red, or 
smaller cells of normoblastic size with a relatively large reticular 
nucleus. If one systematically measures all nuceated reds in a speci- 
men, the small number of these cells is striking unless one include the 
immature nucleated reds of Howell (Fig. 113, b). 

Megaloblasts. — In the marrow always are found nucleated reds 
(Fig. 113, f) , which are from tw T o to four times the size of an ordinary 
red blood-cell. They are round or oval. The protoplasm makes up 
most of the cell, and is often polychromatophilic, but the polychro- 
matophilia may be explained rather by youth than by degeneration; 
33 



514 



CLINICAL DIAGNOSIS 



in the case of the primary anaemias they are rich in haemoglobin; in 
the normal marrow they are often pale. In stained specimens the 
nucleus is large, plump, round or oval, especially the former, usually 
central ; in fresh smears it is easily seen, and has a good chromatin 
net-work if a good nuclear stain be used. It is thus seen that these 
cells are larger as a whole, and have a larger nucleus than have other 
nucleated reds, but what should they be called? 

In all reports of blood cases it is necessary to know the writer's 
definition of a megaloblast, for opinions vary much. Some demand 
a large cell, some a large nucleus. Our rule is that both of these specifi- 
cations must be fulfilled, and for reasons to be given later we ask that 
the size of the nucleus shall be at least that of an ordinary non- 
nucleated red (7.5 microns). Pappenheim and others consider that 
megaloblasts have no direct relation to normoblasts, and that from 
certain fine points concerning their nuclei a megaloblast may be 
recognized, even though it be as small as a normoblast. 

The megaloblast of pernicious anaemia differs somewhat from the 
large nucleated red of bone-marrow. The size of both is about the 
same, but the normal bone-marrow megaloblast has usually a round 
nucleus with very distinct margin and chromatin net-work, while 
the nucleus of the megaloblast in the blood in pernicious anaemia is more 
often oval, much less distinct in fresh blood, stains much fainter in the 
smear, has less definite nuclear membrane and chromatin structure, 
and looks flabbier. But these differences are slight and inconstant. 

The significance of the appearance of megaloblasts in the blood has been the 
subject of dispute; Ehrlich, considering that they never occur in the normal 
bone-marrow of an adult, believes them to be the product of a megaloblastic 
degeneration of this tissue due to a toxine, a reversion to the embryonic condi- 
tion, and others say " to the amphibian," and that any attempts to break down the 
distinction between normoblasts and megaloblasts fail from the fact that in 
pernicious anaemia the blood is megaloblastic. (We are inclined to think that the 
expression " reversion to the amphibian type of blood" is much too often used. 
The only amphibian we have studied whose blood resembles that of pernicious 
anaemia is the batrachoseps, and one would hardly call an haemoglobinaemia a 
" reversion," although that is the blood condition in some worms, hence could as 
easily be called a "harking back.") Such megaloblastic degeneration may explain 
their large numbers in the marrow of pernicious anaemia and some other conditions, 
but we fail to find any recent observer who has not easily found them in all normal 
marrows. In our study of bone-marrow, in which many nucleated reds have been 
measured, we have found the predominant cell the immature normoblast, with 
a nucleus between 3 and 4 microns in diameter. The next most common cell is 
a megaloblast, with a nucleus of 7 microns or over in diameter, or in one axis if 
oval. Between these large cells and the immature normoblasts occur every inter- 
mediate size, and yet the group of all of these is not as great as that of the large 
cells which constitute about 15 per cent, of the total number of nucleated reds. This 
applies to specimens with nucleated reds in moderate numbers, not those with 
innumerable nucleated reds in nests. 

It has been shown that in certain animals the nucleated reds are grouped in 
islands, with the centre of megaloblasts surrounded by zones of cells of diminish- 
ing size to the periphery, where normoblasts are found (Bunting). The develop- 



THE BONE-MAEEOW 



515 



ment is not from centre to periphery alone, for in each zone, and especially the 
peripheral, signs of active regeneration are found, and each cell can produce its 
like as well as a smaller form. Ordinarily it is the periphery of these islands 
alone which furnishes new cells to the circulation, but if because of an over- 
demand the islands be encroached upon, the larger cells of the interior will be 
thrown into the circulation. Bunting has shown in a most interesting manner that 
by various blood poisons the peripheral zone of these islands may practically 
be stripped off. Should this occur in pernicious anaemia it is easy to understand 
the large numbers of megaloblasts in the blood, yet why nucleated cells reach the 
circulation in some cases and not in others is not clear, since in some cases the 
marrow is very rich in megaloblasts and none in the peripheral blood, and again 
the blood will show great numbers (blood crises). The bothriocephalus anaemia 
shows that certain specific toxines can produce this " megaloblastic degeneration" 
of the bone-marrow, for as soon as the worm has died the blood at once begins to 
return to its normal condition. 

Karyokinesis of these large cells occurs in the peripheral blood, especially in 
severe anaemia, and is usually one of the final phenomena. 

Microblasts. — By microblast is meant a very small nucleated 
red, under 6 microns in diameter, with a small pycnotic nucleus. 
These occur in the circulation in severe traumatic anaemias, never 
normally; some appear perfect cells, and others as if pinched off 
from larger cells. The former may be the forerunners of microcytes. 

The fate of the nucleus of the red has been the subject of great discussion, 
and still is. Two views have been held: (i) that the mature normoblast extrudes 
its nucleus (Rindfleisch, Howell, e.g.), and (2) the intracellular destruction by 
karyorrhexis and karyolysis (Kolliker, Neumann, e.g.). Those who hold this 
latter opinion admit that the nucleated red may even be seen to extrude its 
nucleus, but consider that this is pathological ; that normally the nucleus goes 
to pieces in the cell, either by solution or by fragmentation, and the process which 
predominates varies with the disease. Many writers believe that all of these 
methods may obtain ; Ehrlich, for instance, that the normoblastic nucleus is 
extruded, and that the macroblastic is absorbed ; Pappenheim, that for both it is 
intracellular ; Bloch, that either is possible. Whether or not the nucleus is 
extruded or disappears within the cell, the cell then flattens somewhat, becoming 
more disk-shaped and then biconcave. But not all are biconcave, some are spherical, 
especially in the embryo, a point emphasized by those holding the absorption view. 
The "degenerations" or nuclear fragments described by Vaughan (page 435) and 
by Cabot (page 480) indicate the intracellular type. Just at present the extrusion 
idea seems to obtain, but perhaps chiefly since so many need the nuclei to explain 
the origin of the platelets. The free nuclei which some emphasize in stained speci- 
mens may have been thrown out of the normoblast by the centrifugalized force of 
the sudden motion of the cells as the specimen is made, and the nucleus of the 
megaloblast remains in the cell, since its specific gravity is nearer that of proto- 
plasm (Ehrlich, Pappenheim). 

The changes in the nucleus are important. By a " pycnotic" 
nucleus is meant one diminished in size, dense, homogeneous, sharply 
defined, sometimes vacuolated, without any good chromatin net-work. 
The Ehrlich stained cells show no structure at all, only a deep uniform 
chromatin stain, but good nuclear dyes show traces. There seems 
a decrease of nuclear fluid and a solution of the chromatin in it. This 
is a preliminary step of karyolysis or absorption, the nucleus taking 



516 



CLINICAL DIAGNOSIS 



a fainter stain till it cannot be distinguished from the surrounding 
protoplasm. It may precede karyorrhexis or fragmentation of the 
nucleus, which fragments may then disappear by karyolysis. The 
normoblastic nucleus may by amitosis divide into polymorphous 
forms, with two or even twelve fragments (Plate I, 34) of equal 
or unequal size, and usually united by a filament, giving beautiful 
rosette pictures. Some attribute this to karyorrhexis rather than to 
abortive mitosis. In a recent case during a blood crisis 55 per cent, 
of the erythroblasts were of this description, some having the nucleus in 
even twelve lobes. Another method suggested by some specimens is 
the disappearance of the most of the nucleus, leaving a few chromatin 
strands and masses. The study of nuclear degenerations should never 
be made with specimens stained with the Ehrlich stain. That is least 
adapted for nuclear changes. One other point well seen in the bone- 
marrow is the varying haemoglobin tinge of the corpuscles, these 
cells showing a much wider variation than those of the blood. 

This could be explained on the ground that the development of haemoglobin 
was an intracellular matter, a gradual process. Some cells seem to reach complete 
haemoglobin development after they lose their nucleus, some before. The ques- 
tion is of interest in the study of anaemias. Are these pale cells in the circulation 
of fixed composition, or only immature and later develop more haemoglobin ? Can a 
normal cell lose some haemoglobin ; that is, can the color-index rise and fall, and 
yet only the same cells remain ? When the color-index falls is it because the 
cells are like depreciated currency, and it rises when these are recalled and 
better issued in their place ? The question may have little practical importance, 
and yet if discussed the much desired result should be greater care in the use 
of terms with which we describe our cases. Arguments from comparative anatomy 
are not satisfactory, yet the evidence goes to show that in lower vertebrates the 
red cells can complete their development in the circulation, while in the mammals 
an imperfect cell is said to be incapable of further development. Among others, 
Gaule and his pupils believe in a haemoglobin " store" in the body, which in case 
of need is carried into the circulation in new corpuscles and returned when the 
extra cells are withdrawn. 

We fear the great trouble is in the haemoglobinometers, and that until careful 
work is done with the best instruments the question will remain unsettled. 

Origin of Red Blood-Cells. — That the ordinary non-nucleated red blood-cells 
come from the nucleated reds is now doubted by few. Up to the end of the 
fourth week of embryonic life all of the blood-cells are nucleated. From that 
time on the number of the non-nucleated cells increases until at the third month 
only about one-sixth to one-eighth are nucleated. At the fifth month they are still 
numerous, but at birth it is rare to find any nucleated red cells in the blood. 

In the earliest embryonic life the vessels are formed from solid cords of cells, 
the peripheral ones of which become the endothelial lining of the vessel wall, 
the internal cells the corpuscles. This process may occur in almost any part of 
the developing organism, and perhaps also in the adult when there is new forma- 
tion of blood-vessels. In addition, in the embryo many mitoses are found in the 
nucleated reds of the circulating blood. 

Before the third month the liver has become the chief seat of blood formation ; 
after the fifth month the spleen and the lymph-glands take up the task; and at 
last the marrow becomes the chief organ. In the child the marrow of the whole 
skeleton has this function, but at about puberty and during adult life only the ribs 
and some of the flat bones. Howell considers that callus, for instance that fol- 



THE BONE-MARKOW 



517 



lowing a fracture, may in the adult also for a while furnish centres for haemo- 
genesis. In the adult it would seem as if the spleen could resume this function 
in leukaemia and anaemia. 

Removal of the spleen causes little anaemia, but after about a month begins a 
long continued rise of small mononucfears, and in some conditions the blood is even 
leukemic, and then after about twelve months an eosinophilia of even extreme de- 
gree. These phenomena are now explained as manifestations of the vicarious activ- 
ity, first, of lymph-glands then of the bone-marrow, for the spleen. The chief 
function of the spleen seems to be to remove old reds and leucocytes from the cir- 
culation, and the acute spleen tumor in some conditions is due to the great number 
of leucocytes ingested (spodogenic splenic tumor). 

In the embryo the blood-cells are at first without haemoglobin. At this time 
there are no true leucocytes and none appear until after the formation of red cell's 
is active. The ernbryologists have shown that before the appearance of leucocytes 
in disease of the embryo the red blood-cells are amoeboid, perhaps phagocytic, 
which is interesting, since in certain blood diseases of the adult there is at least 
a suggestion of these two functions. 

In lymphatic leukaemia (certain acute cases) the view is still held by some that 
the increased cells are " red cells" without haemoglobin, and the converse Pappen- 
heim holds to be true in severe anaemias, some of the large lymphocytes developing 
to megaloblasts instead of to small lymphocytes. 

Howell was the first to demonstrate in the cat " ancestral corpuscles" which 
resemble the red blood-cells of reptiles, being large, oval, semifluid red cells, with a 
deeply stained oval nucleus. These cells were later described by Engel as " metro- 
cytes of the second generation," those of the first generation having a large chro- 
matin-rich nucleus. Later such cells never, normally at least, reach the circu- 
lation, and Engel thinks they are no longer formed. 

For the study of the young red cells the blood of embryo mice is to be espe- 
cially recommended. Here a great variety of changes in the nucleus and in granu- 
lation of the protoplasm may be demonstrated. 

White Blood-Cells. — For the best recent study of bone-marrow, 
see Schur and Lowy. 43 

A. GRANULAR CELLS 

L Neutrophiles. Neutrophile myelocytes. 

I. Typical myelocytes ; cells from 12 to 15 microns in diameter, 
with a large round nucleus, the protoplasm scanty, forming often 
a thin rim around the nucleus, and finely granular. These cells are 
by far the most numerous in the marrow, but on account of their size 
seem even more so than is the case. The nucleus is often hard to 
make out. In the bone-marrow may also be seen beautiful larger 
myelocytes with faint nuclei, which, however, ate not often found 
well preserved since they go to pieces so readily, and which occur in 
the blood only in leukaemia, " Cornil's marrow cell." In the fresh mar- 
row some of the myelocytes have a very small, dense, round nucleus, 
which we think is a post-mortem change from the loss of nuclear 
fluid. All transitions from those cells with a round nucleus to the 
typical leucocytes are present on the one side, all transitions from 
large mononuclears wit v but few or no granules t) those full of 
granules, on the other 

^Zeitschr. f. klm. Med., Bd. 40. 



518 



CLIXICAL DIAGNOSIS 



2. Cells similar to the above, but much smaller. The nucleus 
indented, or slightly polymorphonuclear, but staining faintly. — " tran- 
sitional cells." 

3. Typical leucocytes. 

II. Eosinophiles, always relatively few in number. 

1. Eosinophile myelocytes. Large cells with pale nucleus, scanty 
protoplasm filled with eosinophile granules, otherwise similar to the 
above mentioned neutrophile cells. 

2. Similar to the above, but smaller ; the nucleus indented or 
slightly polymorphous. All gradations may now be found to typical 

3. Eosinophile leucocytes. 

III. Basophiles. 

1. Mastzellen, which, however, are rather rare to find. These 
cells have nuclei of a variety of shapes, yet usually polymorphous 
(see page 506). Mononuclear Mastzellen occur (Engel). These are, 
at least, hard to recognize, since the young a and e granules are 
quite basophilic. 

2. V arious cells with violet granules, which vary in size. The 
cells are rather small. These, although containing basophiie granules, 
are not typical Mastzellen. In this connection it should be men- 
tioned here that the /? granules may occur in the eosinophile cells or 
by themselves. 

3. Polymorphous cells, with fine basophiie granules. These may 
be neutrophile cells stained by the "tricky" methylene blue (Schur 
and Lowy). 

B. NON-GRANULAR CELLS 

1. Lymphocytes. Size of red blood-cells, nucleus rich in chro- 
matin, protoplasm a narrow rim. These cells are the second most 
numerous cells and often seem naked nuclei. 

Among these are the " protoleucocytes" of Osier, solid-looking 
lymphoid elements from 2.5 to 5 microns in diameter, which resemble 
free nuclei ; some have a rim of protoplasm. From these " erythro- 
blasts" develop (see page 519). 

2. Medium-sized lymphocytes with more protoplasm and a smaller 
often eccentric nucleus. 

3. Very large cells with general character of lymphocytes which 
occur in the blood in some acute leukaemias, but none normally; 
"Large lymphocyte" (Ehrlich. Frankel. Pappenheim) ; Grawitz's 
" unripe cell." Wolff's " indifferent lymphoid .cell." Xaegeli's " mye- 
loblast," Troje's " marrow-cell.' The nucleus stains faintly, is sel- 
dom lobulated, is very pale and poor in chromatin, the protoplasm is 
faintly basophilic. 

Also to be mentioned are cells, common enough, which in the 
fresh exactly resemble normoblasts (immature), except they have no 



THE BONE-MAEKOW 



519 



haemoglobin. The nucleus is that of Howell's immature red, perfectly 
round, with sharp margin, distinct chromatin net-work, and clear 
hyaline protoplasm. They are from 9 to 12 microns in diameter. 
These are the erythroblasts of Osier, Lowit, and Howell. 

Lowit described as " leucoblasts" cells with relatively large nuclei containing 
one or two chromatin masses which are sometimes irregular in shape, and from 
which a system of delicate lines and bands radiate to the nuclear membrane, which 
membrane is distinctly doubly contoured, and has on its inner surface projections 
which are connected with the infranuclear net-work. Concerning their method of 
division, upon which Lowit lays much stress, it is not easy to decide. 

Ehrlich believed the true lymphocyte came from the lymph-glands ; others say 
from the bone-marrow. Some have tried to distinguish morphologically those from 
the marrow from those from glands (Rubenstein) . The question now is, "Do 
any come from lymph-glands ?" thus admitting that typical " lymphocytes" are an 
important constituent cell of the marrow. Michaelis and Wolff tried to differen- 
tiate these cells on the basis of their future history, the lymphocytes from lymph 
glands remaining such, the " lymphoid" cells of the marrow being capable of further 
development to a granular cell. But this capability does not aid us much in saying 
which the individual cell now before us is, although these writers did describe 
slight differences in their staining reactions. And yet this distinction between 
lymphocytes and lymphoid cells is probably just. Many workers fall back upon 
such indifferent lymphoid cells as young forms, naming them " protoleucocytes" 
(Osier), etc., and consider that from them develop colorless cells which cor- 
respond to the leucoblast and erythroblast of Lowit and Howell, and from these 
the whole series of reds and whites. The lymphocyte with diffusely staining notched 
nucleus (Rieder's cell) is probably an old form of lymphocyte. The small 
mononuclears with round vesicular nucleus, delicate chromatin net-work, and rather 
broad band of basophilic protoplasm with smooth margin, are young cells which 
resemble only in appearance those of the normal blood, and themselves do not 
belong there. The lymphocytosis of young babies is unquestioned, and yet the most 
rational explanation for this is that there is an overproduction of leucocytes which 
did not exist at birth, since then there was no function for the cell. Yet this would 
mean that young leucocytes are lymphoid cells. The same might be said for the 
lymphocytes of the digestive leucocytosis. 

Among marrow cells are forms which never reach the circulation ; probably 
young (also old?) leucocytes and red blood-cells, and perhaps undifferentiated cells 
the ancestors of both series, unless one agrees with Bizzozero that none of the ances- 
tors of red cells are without haemoglobin. The variety of forms of cells found is so 
great that not one sharp dividing line can be drawn to separate a single group, and 
one may find evidence in favor of any ancestral tree he wishes. Two main views 
are held, the one that the youngest cells in the series are very large, with large, 
faintly staining nuclei, and protoplasm which very quickly goes to pieces, hence 
they are not always found ; the other that they are small. According to the 
former, in each succeeding generation the cells become smaller and more resistant ; 
the large fragile mononuclears develop granules and become large myelocytes, in 
the next generation are ordinary myelocytes, and these give rise to leucocytes. Of 
course, too much stress may have been laid on the shape of the nucleus as an age 
sign ; it may be that a certain amount of irregularity in the nucleus is an expression 
of an amoebic cell, and that the mononuclear granular cells in some exudates are 
leucocytes which have resumed a resting form. The same large white cells may 
develop haemoglobin in their protoplasm and become megaloblasts, the succeeding 
generations of which are the intermediate, then immature nucleated reds, then the 
mature, then the ordinary red corpuscles. 

The other view considers small lymphoid elements, some even like naked nuclei, 
as the youngest cells, from which, by increased size and differentiation, myelocytes 
and erythroblasts arise, then to again diminish in size with advancing age. 



520 



CLINICAL DIAGNOSIS 



Most will now agree that there is a large group of indifferent cells which will 
develop in whatever direction (red or white) necessity demands. The only ques- 
tion is, Which are these cells ? 

The development is more by " steps" than by a gradual transition, and those 
of each step are able to produce others of their kind as well as those of the suc- 
ceeding generation (in point of size, etc.). The picture is still more complicated, 
since the line of descent of these cells is not single, but new ancestors can be found 
at each step in the progress, so that to trace backward is more like following a 
stream toward its source. It is a single river at it's mouth, but as we go toward 
its source many tributaries are found which contribute to its volume. Thus Pap- 
penheim traces normoblasts from small lymphocytes, megaloblasts from large 
lymphocytes, and considers the polychromatophilic group evidence of the trans- 
formation from a basophilic lymphocyte to a red cell ; subsequent workers trace 
normoblasts from megaloblasts. Normoblasts certainly can produce normoblasts, 
and megaloblasts megaloblasts. Again the granulation may appear in cells with 
nuclei at various stages of deformity, as if the changes in the nucleus from round 
to polymorphous bore little parallelism to the development of granules. 

We cannot here take up the question of the origin of leucocytes and perhaps 
red cells in other organs. The above remarks are not intended as a resume of the 
subject, but an answer to many of the questions suggested to students by the study 
of bone-marrow. We merely mention Nothnagel's case of general osteosclerosis, 
with the entire marrow practically functionless, yet a normal count of neutrophiles ; 
also the presence of mononuclear granular cells in areas of inflammatory infil- 
tration. 

4. Pigmented cells, often absent. 

5. Giant-cells. 

(a) Megakaryocytes with one large irregular coiled nucleus. 
" Giant-cells with budding nuclei." 

These are the " hsematoblasts" of Foa and Salvioli, which they say give rise to 
smaller hyaline cells, which develop haemoglobin to form nucleated reds. These 
cells are seldom found in the stained specimen, although masses of detritus which 
one may suspect to arise from them are found. These cells occur in the circulation 
in a leucocytosis, and are filtered out in the lung (see Plate II, 11). 

(b) Multinuclear cells. Osteoclasts. 

Many cells are seen, especially in fresh specimens, with very interesting degen- 
erations and inclusions. Some large mononuclear cells contain large globules or 
droplets resembling myelin, droplets about 3 microns in diameter, rather uniform 
in size, and with the yellowish shimmer of the myelin droplets of the sputum cells. 
Some cells are filled with very large granules with the color and refractility of a 
granule (see Fig. 115, e). Such cells Howell found in the marrow of the cat in good 
numbers, and considers them to play an important part in metabolic changes in the 
marrow. In other cells occur globules of fluid, giving them a vacuolated appear- 
ance. Large "dropsical" projections both of protoplasm and of nucleus are also 
seen. 

Unlike the red cells, in the leucocytes it is much easier to trace the degen- 
erations. In normal blood practically all the leucocytes are normal, but when there 
is a leucocytosis or especially in the leukaemias many cells are seen concerning the 
death marks of which there is little doubt. The lymphocytes are almost devoid 
of protoplasm, the nucleus small pycnotic and indented, or even polymorphous 
(Rieder's cells) (Plate II, 17). The polymorphonuclear granular cells have nuclei 
very pycnotic and fragmented, although probably a chromatin thread always con- 
nects the fragments. For an interesting manner in which the neutrophile leuco- 
cytes may be classified, based on the number of nuclear fragments^ and the use to 
which such a classification may be put, see the publications of Arneith. 44 



Zeitschr. f. klin. Med., 1904, Bd. 54, p. 232. 



THE BLOOD: LEUCOCYTOSIS 



521 



Concerning the large pale nuclei without protoplasm there is doubt, since they 
could be the very sensitive young cells destroyed in the preparation of the specimen. 
But the similar changes in the small mononuclears, which may in leukaemia be a 
feature of even the majority of the cells, suggest very strongly that they are 
degenerations. 

Late in leukaemia it would seem (said Ehrlich) as if the ability to develop 
neutrophile granules might be lost, and clear cells are found which resemble the 
granular cells in every way except they have no granules. 

All these questions would be much less interesting if the cells have the ephem- 
eral history which some ascribe to them. Winternitz (quoted from Grawitz) esti- 
mated that in the dog the lymph supplied the blood through the lymph-duct daily a 
number of lymphocytes equal to more than half the total number in the body. If 
this be true, the chief function of most of the cells must be to increase the proteid 
content of the plasma. A similar question is the source of the pus-cells in cases 
with great pus formation, as cystitis and bronchitis or bronchiectasis, in which by 
actual estimation the person loses daily a number of white cells almost equal to the 
total number in his circulation at any one time. 

Foetal Blood. — In the three-months' human embryo Engel found nucleated 
red cells of normal and large size, " metrocytes of II. Generation " ; that is, large 
spherical nucleated reds, 12 to 20 microns in diameter, rich in protoplasm, the 
nucleus relatively small, 3.5 to 6 microns in diameter; but in some cells 17 to 20 
microns in size the nucleus was 7 to 8 microns. These cells occurred in frequency 
of from 4 to 6 per 100 normal reds. (Metrocytes of I. Generation he describes from 
mouse embryo's blood as spherical cells from two to three times the size of a normal 
red cell, the nucleus often in mitosis and filling but a relatively small part of the 
cell; this, he says, is not a megaloblast nor a gigantoblast. At this stage there are 
no non-nucleated reds and no leucocytes.) At this stage occur two forms of normo- 
blasts, — those staining orange, from 5 to 9 microns in diameter and the nucleus 
3.5 to 5 microns; those staining red (Ehrlich stain), about 7 to 8 microns in 
diameter, with a relatively large nucleus rich in structure 5 to 6 microns large, the 
protoplasm scanty and ragged ; in this latter group are some large cells 16 microns 
in diameter and a nucleus of 11 microns; these are Ehrlich's megaloblasts. 

The other cells were free metrocyte nuclei, lymphocytes, neutrophile mye- 
locytes, and leucocytes. 

In embryos of 6 cm. length the non-nucleated reds were to the nucleated 
as 12:1; of 12 cm. embryo, 55:1; of 16 cm. 150:1; of 19 cm. 176:1. In 
the 6 cm. embryo the metrocytes were 4 per cent, of the reds ; in the 12 cm., 0.25 
per cent., and later none. The leucocytes in the 6 cm. embryo were to the reds as 
1 : 500 to 1000. 

Engel admits that embryos of the same age differ so that he could not tell the 
age of the embryo by studying its blood. 

We have had opportunity to study the blood of a foetus 15 cm. long, and found 
red cells, 1,168,000; haemoglobin, 25 per cent.; leucocytes, 9000. Nucleated reds, 
1 : 19 of total reds, normoblasts and intermediates, beautiful polychromatophilia. 

In an embryo 20 cm. long we found reds, 2,652,000 ; leucocytes, 28,000 ; haemo- 
globin, 38 per cent. 

In an embryo of 23 cm. Engel found the reds (heart's blood), 3,300,000; haemo- 
globin, 80 per cent. ; leucocytes, 40,000. Nucleated reds were to non-nucleated as 
1 : 120, and all normoblasts. Of the leucocytes, the granular were to the non- 
granular as 2:5; neutrophile myelocytes and leucocytes present with all transitions, 
and a few eosinophiles. 

The blood of a 27 cm. embryo contained nucleated and non-nucleated reds in 
relation of 1 : 200, leucocytes to erythrocytes as 1 : 90, polymorphonuclears to mono- 
nuclears as 4:5. 



Leucocytosis. — By this term was meant an increase above nor- 
mal of the white cells of the blood, but the term now means a transi- 



522 



CLINICAL DIAGNOSIS 



tory, symptomatic, absolute increase of the polymorphonuclear neu- 
trophiles especially, in the peripheral blood, above the maximum that 
is normal for a given individual in the condition in which he at that 
time finds himself. 

In general 10,000 leucocytes per cubic millimetre is the limit an 
increase above which is said to be pathological. But the matter is a 
relative one, ana >nly when so considered does the condition have the 
clinical value claimed for it. Some persons have normally a leucocyte 
count of 10,000 to 12,000. The count also depends on the con- 
dition of the person. For instance, if cachectic with a leucocyte count 
of 4000, a rise to 8000 would mean as much as a rise to 20,000 would 
for some normal persons. This was beautifully exemplified in one 
case of typhoid fever with a leucocyte count of 1600. A parotitis 
developed and the leucocytes promptly rose to 3200, a true leucocytosis 
for that person at that time. 

A leucocytosis also is transitory and symptomatic, and this distin- 
guishes it from leukaemia. 

The term leucocytosis now has a very special meaning. It is used 
of an absolute increase of the polymorphonuclear neutrophile cells. 
An increase of one of the other types of white cells is named 
according to the cell increased ; for instance, if it is the mononuclear 
non-granular cells, lymphocytosis; if the polymorphonuclear eosin- 
ophiles, eosinophilia ; if the mononuclear granular cells, myelsemia, 
etc. It is very seldom that one group of cells alone is increased; 
usually others are to a less degree ; but since there is evidence that the 
various cells are not all related very closely at least to one another, 
it is their absolute number which is to be considered rather than their 
relative, that is, than their percentages or " formula." With even a 
diminished per cent., providing the total count be raised, the absolute 
number may have increased, while the reverse also is true that when 
the percentage seems to indicate an increase the absolute number may 
have dropped if there is a diminution of the total number. 

Or a group of cells may remain unchanged, while other groups change much. 

A good illustration of this is the following, a case of Frazier and Halloway : 
Count, 13,040; polymorphonuclears, 78.2 per cent, (i.e., 10,197); small mono- 
nuclears, 16.8 per cent. (2101). The total count rose to 54,960; polymorpho- 
nuclears, 90.4 per cent. (49,684) ; small mononuclears, 4 per cent. (2198;. 

The " general type" of leucocytosis — i.e., an equal increase of 
all the leucocytes — is rarely seen. It results from stasis of blood in 
the capillaries, following a cold bath, or massage, — e.g. Also cases 
of the digestive leucocytosis and that of pregnancy, et al, show it in 
some degree. 

Classification (Limbeck). — 1. Physiological: (a) Digestion; 
(b) Pregnancy; (c) Newborn. 2. Pathological: (a) Inflamma- 



THE BLOOD: LEUCOCYTOSIS 



523 



tory; (b) Malignant tumors; (c) Post-hemorrhagic ; (d) Agonal. 
3. After medicinal and therapeutic measures. 4. Various other 
causes, as shock, etc. 

Digestion Leucocytosis. — The leucocytes of a normal person who 
after a fast of twelve or more hours partakes of a rich proteid meal 
will usually rise to about one-third above the normal number. The 
count begins to rise in about one hour as a rule, reaches a maxi- 
mum in from three to five hours, and then decreases. While the 
polymorphonuclear neutrophiles are especially involved, the small 
mononuclears are to some extent, in some cases considerably. For 
some persons no preliminary fast is necessary; in others the leuco- 
cytes do not rise at all. (Limbeck thinks habitual constipation ex- 
plains the latter.) Children show it more markedly than adults, and 
the well nourished than the poorly nourished; it is greatest in the 
infant after his first meal of cow's milk. For the nursing infant it 
is said to be absent, and hence the opinion (Moro) that it is a reac- 
tion against foreign proteid. A rich proteid meal is necessary, hence 
diabetics show it well. Particular stress should be laid upon this 
point, that the meal should be unusually large, for the leucocytes are 
even fewer after a light meal (also after some heavy ones), or again 
they may not change. It is absent in the herbivorous animals, and 
little in man after a vegetable meal. 

The explanation is in doubt. One thing is quite certain, that it is due to the 
absorbed products of proteid digestion, which have a positive chemotactic influence. 
Hofmeister suggests the proliferation of the large masses of lymphoid tissue along 
■ the intestine, due to the stimulation of the digestive processes, to be the cause ; 
hence it is a mixed leucocytosis. The lymphocytosis is, however, not always 
present. 

Jaffe says that in children the leucocytosis is not dependent on the 
meal, but is periodic. 

The reverse relation is also true. Persons in starvation show a 
low leucocyte count ; Succi, who fasted seven days, had a count of 
861 per cubic millimetre, while the insane with melancholia often 
have counts below 3000. On the other hand, well-nourished persons 
often have counts from 10,000 to 12,000. 

The function of the leucocytes is probably not alone protective, but they play 
an important part in absorption, transportation, and assimilation of food ; hence 
their number depends much on the age and nutritional condition of the person. 

There is some value in the digestion leucocytosis to aid in differ- 
entiating between pernicious anaemia and cancer of the stomach. In 
severe blood diseases, pernicious anaemia, and in ulcer and other 
gastric diseases it is present, while in cancer of the stomach even 
fairly early, it is sometimes absent, but not always. It is absent in 



524 



CLINICAL DIAGNOSIS 



some benign conditions. 45 Gastric catarrh and involvement of the 
lymph-glands are given as its explanation. We wish to emphasize 
the necessity of giving a rich proteid meal and of counting the leuco- 
cytes once an hour. Only a considerable rise is of value. 

Leucocytosis of Pregnancy. — About 75 per cent, of women during" 
the last months of pregnancy show a count above normal, an average 
about 13,000 per cubic millimetre. This is especially true of primi- 
parse, and yet the explanation is more the youth and the nutritional 
condition of the patient than the fact that she has had no previous 
pregnancies. The count rises until the end of pregnancy, and then 
diminishes in from four to fourteen days after delivery. The differ- 
ential count may remain practically normal, yet it is the polymorpho- 
nuclear neutrophiles that are especially involved. In multiparse there 
is also a rise, but it is within physiological limits. 

The explanation has been disputed. It is agreed that it is not the pregnancy 
per sc. V. Limbeck considers it a prolonged digestion leucocytosis, due to the 
need of additional nourishment for the mother and child. In favor of this is the 
absence of a digestion leucocytosis or even a diminution of the count after a heavy 
meal, due, it is said, to a migration of leucocytes to the placenta, where is the 
greatest accumulation of the positively chemotactic products of digestion. The 
condition of the breasts is also suspected ; others ascribe h to an overactivity of the 
lymphatic system. But the view most commonly held now is a slight autointoxica- 
tion, against which the primipara reacts better than a multipara. Thomson found 
that of 33 counts on twelve pregnant women made during the eight months of 
pregnancy but one was below 7000; the highest 13,200. 

But the question is, What is the usual count for a normal woman? Is it 5500? 
If so, pregnancy causes in all cases a relative rise, and in most an absolute 
leucocytosis. 

Zangemeister and Wagner 46 think the question not quite so clear. Of 47 
normal non-pregnant women, all under practically the same conditions, from twenty- 
one to thirty-four years of age, 35 (74 per cent.) had a count above 10,000 (mean 
about 12,500). The leucocytes of pregnant women (57 cases) varied within the 
same limits as non-pregnant (70 per cent, above 10,000; mean count between 
12,500 and 15,000), nor did the number of previous pregnancies seem to make any 
difference. The counts which these writers report are about the same as those of 
the writers claiming a leucocytosis as a feature of pregnancy, only the former claim 
that normal non-pregnant women give the same. During labor, of 63 cases there 
was a rise even to three times the previous count in nearly all cases, with the max- 
imum at or just after delivery. This was especially marked in cases of prolonged 
labor or of those who suffered greatly. In quick, easy labors the rise is insignificant. 

In 75 cases during the puerperium there was a rapid decrease to normal. On 
the seventh or eighth day an increase of mononuclears, with the involution of the 
uterus (Rouslacroix and Benoit). The study of two cases of version led them to 
think the cause of the rise was the contractions of the uterus. 

In pathological cases the leucocytes give no aid in diagnosis or prognosis, since 
as high counts are seen in the physiological cases. 

Lobenstein 47 considers that there is a leucocytosis' of pregnancy, the average of 
50 cases during the ninth month being 11,854 f° r primiparse, and 9346 for multi- 
paras; and on the third day of the puerperium, 13,200 for primiparae, and 11,600 

45 Rencki, Arch. f. Verdauungskr., Bd. vii. 

46 Deut. med. Wochenschr., July 31, 1902. 

47 Am. Jour. Med. Sci., 1004, vol. cxxviii. p. 281. 



THE BLOOD: LEUCOCYTOSIS 



525 



for multipara. These figures are too nearly normal to name them leucocytoses. In 
20 cases the digestion leucocytosis was tried, found present in 13, but an actual 
diminution in the count in 6. Of 13 cases of eclampsia, in 6 mild cases the highest 
count was 31,000; in 6 severe, 40,000 to 50,000; and in one severe case, 106,000 
and death. He concludes that the leucocytosis is roughly parallel to the degree of 
intoxication and to the resistance. A low count and a rapidly falling count are bad 
signs. 

Leucocytosis of the Newborn. — Although the foetus has so many 
blood-building organs yet the leucocyte count is very low, since as 
yet there is no function for these cells (Askanazy). The state- 
ment usually made is that at birth there is a leucocytosis of from 
17,000 to 21,000, and after the first feeding a rise to from 26,000 to 
36,000, with the increase chiefly in the number of small mononu- 
clears. Examination of the infant's blood exactly at birth, however, 
in case the teacher wishes to demonstrate a true lymphocytosis, will 
assure the disappointed one that this is by no means the case, and he 
will usually find a condition of the leucocytes quite like that of the adult. 
The question has been studied by Gundobin, Carstanjen, and War- 
field, 48 with the following results. On the first day after birth the aver- 
age leucocytosis is about 26,000 (11,700 to 34,700) ; on the third day, 
the average is 13,270, and on the eleventh day 15,740. For the first 
few days there is an absolute increase in the number of polymorphonu- 
clear neutrophiles, with a percentage of 70.42 on the first day, 53.16 
on the third, and 34.2 on the eleventh. The large mononuclears and 
transitionals are high, being 10.76 per cent., 16.67 P er cent., and 
15.98 per cent, respectively on these three days. The eosinophiles 
vary much; Mastzellen and myelocytes are few and rare. It is not 
until the eleventh day that the count which is usually considered 
normal for infants, with 40 per cent, small mononuclears, appears. 

This high count of the leucocytes has been explained by a con- 
centration of the blood or a digestion leucocytosis, but the more 
rational explanation is the rapid blood formation at that age. Al- 
though normal infants vary much, yet this rather high count may 
continue until from the third to the sixth year, after which time the 
blood picture of the adult prevails. During these early years the 
polymorphonuclear neutrophiles vary from 18 to 40 per cent., the small 
mononuclears from 40 to 60 per cent, of the total number, and often 
there is a slight increase in the eosinophile cells. 

Leucocytosis of Inflammations and Various Febrile Diseases. — There 
is an absolute increase of the polymorphonuclear neutrophile cells 
especially accompanying most inflammations, most acute infections, 
and other febrile diseases, which is roughly parallel to the temperature, 
and which depends especially upon the activity of the inflammatory 
process and the condition of the patient. 

48 Amer. Medicine, September 20, igo2. 



526 



CLINICAL DIAGNOSIS 



The following general statements may be made. Whatever the immediate 
cause, a leucocytosis represents the reaction of the individual to the disease. In 
those conditions usually accompanied by a leucocytosis a high count means a 
vigorous reaction, little more ; a low count may mean a poor reaction, hence indi- 
cate a poor prognosis, or the infection may be of so mild a degree that it can elicit 
little or no reaction. 

On the other hand, diseases differ in their ability to produce a leucocytosis : 
some do practically always, as pneumonia, and in a degree roughly parallel to the 
virulence ; some never, as measles, malaria, and tuberculosis ; some perhaps an 
early leucocytosis followed by a leucopenia, claimed for typhoid fever, but doubted 
by most ; some none at first, then a rising count, as typhus fever, some cases of 
influenza, and smallpox. Some diseases ordinarily without leucocytosis may in 
cases of great severity show one, as malaria. In certain cases much depends on 
the situation of the infection, as in typhoid fever, which infection, when it causes 
empyema or periostitis, is accompanied by a rise of leucocytes ; also tuberculosis 
of the meninges, and caseous pneumonia. 

In cases of local infections, as abscess formation, the leucocytosis is a symp- 
tom related to the fever and other toxic features, and evidently like them caused 
by, and its severity determined by, the toxine absorbed ; for following operation 
and free drainage both quickly drop to normal. For much the same reason the 
count runs quite parallel to the richness of the exudate in pus-cells. 

It is not the exudate formation alone which governs the leucocyte count, for 
cases with free drainage of pus may lose enormous numbers of white cells daily 
(almost as many as are in the circulation at any one time), and yet show a 
normal count. This is well seen in some cases of chronic bronchitis, bronchiectasis, 
cystitis, etc., in various bone and joint abscesses with discharging sinuses, in em- 
pyema after operation, etc. The agent causing the leucocytosis seems the same 
as that causing fever, for they usually begin and end together, depending on the 
free drainage of the exudate. 

Of course one would expect that a great loss of cells in an exudate would mean 
a diminution in those of the blood, and in acute cases, a spreading peritonitis for 
instance, this is thought to be the explanation of the sudden drop in the count 
of the blood. 

In general, the leucocyte count runs in no way parallel to the severity of the 
condition ; a simple local felon may cause as high a leucocytosis as an appendix 
abscess, and a fatal pneumonia as little rise as a boil. 

Among the conditions causing leucocytosis are: Acute lobar pneu- 
monia, the best studied (page 601). 

Acute tubercular pneumonia (page 596). 
Acute articular rheumatism (page 605). 
Diphtheria (page 595). 

Acute cerebro-spinal meningitis caused a leucocytosis in all 
of 21 cases (Osier); in 4, over 40,000; the highest, 47,000. The 
leucocyte count is of no especial value in distinguishing the various 
forms of meningitis, since it is also present in the tuberculous. 

An ordinary acute follicular tonsillitis usually causes a leu- 
cocytosis. This was true of 18 of 26 of our recent cases (12, from 
10,000 to 15,000; 3, above 20,000; the highest, 27,000). There was 
considerable fever in all the cases with high counts. 

Scarlet fever (page 595). 

Mumps. The occurrence of a leucocytosis is disputed. 

In whooping-cough the leucocytes, especially the lymphocytes, 



THE BLOOD: LEUCOCYTOSIS 



527 



are increased three or four times the normal amount, averaging 40,000, 
the degree of leucocytosis depending on the severity of the case and 
its complications. It is more pronounced the younger the child is. 
The early appearance of the leucocytosis is important in diagnosis. The 
rise is chiefly of the lymphocytes, but not entirely. It begins with the 
disease, during the catarrhal stage, and continues longer than the 
paroxysms, is maximal during convalescence. Others claim it is a 
true leucocytosis ; again others, that the formula is little disturbed. 

Rabies sometimes causes a true leucocytosis of even 25,000, with 
98 per cent. pmn. n. 

Erysipelas causes a leucocytosis which runs fairly parallel to the 
temperature, of 10,000 to 20,000 in mild cases, 20,000 to 30,000 in 
more severe. Its polymorphonuclear neutrophile character is more 
marked in adults than in children. These cells may be 92 per cent, 
in fatal cases. As the count falls, the eosinophiles may rise consid- 
erably. 

In 6 cases the leucocytes were normal in 2, moderately elevated in 2, and 26,000 
and 34,500 in the other two. The red cells were normal in all. 

In acute ulcerative endocarditis the leucocytes are high as 
a rule, especially in those cases running a protracted course, an impor- 
tant point in diagnosis, any long continued leucocytosis suggesting 
this. In rapidly fatal cases there may be no rise. 

In 6 cases recently at death the count stood 7070, 13,600 (it had fallen from 
34,000), 17,000, 47,000, and 48,000 (it had risen from 9800). In another case, 
12,000. 

In intestinal obstruction the leucocytes rise rapidly to about 
16,000 when partial, to 20,000 or more when complete; with over 
20,000 cells within the first twenty-four hours the chances are in favor 
of gangrene. This rise of leucocytes may be of value in a case of 
suspected post-operative obstruction. (Bloodgood.) 

Following a thyroidectomy the myxedema is accompanied by a 
count of even 49,000. 

Smallpox (page 595). 

Cholera. — At the algid stage the leucocytes may number from 
40,000 to 60,000, and rapidly disappear during the stage of reaction. 

Pyogenic inflammations of the serous membranes, meninges, 
pleura, pericardium, peritoneum, not tuberculous, are accompanied by 
a leucocytosis which bears some relation to the cellular richness of the 
exudate in leucocytes, more to the fever. The count varies with the 
progress of the disease, since it may drop to normal while the process 
is stationary even if the temperature remains elevated, until a slight 



528 CLINICAL DIAGNOSIS 

spreading of the process causes a rapidly rising count. This is well 
seen in pelvic inflammations. 

In 99 cases of pleurisy with effusion the red cells were practically nor- 
mal ; in 65 the leucocytes were below 10,000 cells, and in but three of the remain- 
ing were they over 15,000. Cabot reports almost exactly the same figures for 
the Massachusetts General Hospital (314 cases; 33 per cent, above 10.000; 6 per 
cent, above 15,000). The low counts are interesting since so many such cases are 
clearly tuberculous. 

In empyema, on the other hand, there is almost always a leucocytosis, except 
in cases (14 per cent.) allowed to remain without operation for some time. 

In 37 cases of acute fibrinous pleurisy the leucocytes varied from 10,000 to 
22,900 in 24. In the rest the count was normal. 

Influenza is a term applied to a wide group of cases, but with 
the diagnosis seldom confirmed by cultivating the organism. The dem- 
onstration that many cases of bronchiectasis and chronic bronchitis 
are really la grippe throws considerable doubt on the figures given 
of the blood-findings. But accepting the diagnoses as they stand, the 
leucocytes are normal in about two-thirds of the cases (Cabot), mod- 
erately increased in the rest. Blum 49 states that in the typhoidal or 
abdominal form there is leucopenia. Gerber 50 states that the leuco- 
cytes rise not at the height of the disease, but as the fever falls ; that a 
count of 20,000 cells indicates pneumonia. During the rise the eosino- 
philes decrease or disappear. 

In almost half of our cases the count was above 10,000 at the height of the 
disease, reaching even 25,000. What is of more interest is that nearly all the cases 
in which several counts were made showed early a very low count, then a sharp 
rise, which fell after the temperature was normal. This may explain why in the 
cases with but one count the leucocytes may be low, even 3000 to 5000 when the 
temperature is 100 0 to 105 0 , and high when the temperature is normal. It also 
shows that for diagnosis it is not one count that is of value, but the leucocyte 
curve. 

Any pyogenic processes of mucous membranes accompanied by 
fever may cause a leucocytosis, as enteritis, urethritis, etc. 

Acute bronchitis is accompanied by a leucocytosis which con- 
tinues as long as the fever. The count was from 10,000 to 20,000 
in 30 of our 67 cases. 

In chronic bronchitis the emphysema and attending cyanosis 
may explain the few cases with slight leucocytosis, present in just 
half of our cases. 

The red counts averaged high, the mean being 5,000,000. Of 
25 cases, 3 were above 7,000,000 (maximum 7,900,000). 

In a case of true foetid bronchitis, 22,500. 

In 1 1 cases of bronchiectasis the leucocytes were 20,000 in 2; 

49 Wien. klin. Wochenschr., 1899. 
50 Wien. klin. Wochenschr., 1900. 



THE BLOOD : LEUCOCYTOSIS 



529 



between 10,000 and 20,000 in 4; normal in the others. The 6 with 
leucocytosis ran a slight temperature. 

Among the local pns processes in which the leucocyte count is an 
advantage are appendicitis (pag*e 605), pelvic inflammatory disease 
(except tuberculous, and mild in gonorrhceal) , abscess of the liver, 
empyema of the gall-bladder, ovarian abscess, abscess of the brain, etc. 

In abscess of the lung counts as high as 60,000 have been re- 
ported, in other cases very low. In 3 recent cases they were 8100, 
12,300 and 12,500. 

In two recent cases of gangrene of the lung the leucocytes 
numbered 20,000 and 48,000. 

In 25 cases of gonorrhceal arthritis, the mean red count was 4,500,000; 
lowest, 3,600,000 ; the mean leucocyte count was 9000 ; 8 of 23 cases were between 
10,000 and 20,000. 

In perirenal abscess, 5 cases, the leucocytes varied from 19,000 
to 36,000; pyelitis, 4 cases, the leucocytes were from 10,600 to 
19,500. 

In pyelonephrosis, 2 cases, 18,000 and 28,500; hydronephro- 
sis, 2 cases, 6400 and 9000 ; pyelonephritis, 1 case, 8000. 

In renal calculus, 4 cases, the leucocytes during the colic were 
from 12,000 to 18,000. 

In gout the red cells are practically normal, and 5,000,000 or over 
in but 2 cases (of 13 cases the lowest was 4,300,000). The leucocytes 
rise with the onset of an acute joint attack. (In 18 cases there was 
a mild leucocytosis, — 10,000 to 14,000 in 7 cases.) In a case counted 
daily, simultaneous with the rise in temperature and tenderness of 
the joints, the leucocytes rose soon to 31,000, and fell again as joint 
symptoms subsided. 

There is a leucocytosis in diabetic coma and in uremia. 

The question of a post-operative leucocytosis which is not due 
to infection is very important from a surgical point of view, in the 
diagnosis of sequelae to an operation. 51 King 52 considers that a 
curve with an increase of 5000 to 10,000 cells during the first six to 
thirty-six hours is a normal post-operative condition, provided the 
rise is not longer sustained. Others give the limits as from thirty-six 
hours to five days. It reaches its maximum during the first twelve 
hours. The height bears no relation to pulse or temperature. If the 
rise is over 10,000 cells, and is sustained longer than a few hours, 
it is very suspicious. The normal ante-operative count for each case 
should always be determined before operation. The highest count 

51 Frazier and Halloway, Contrib. from the Wm. Pepper Lab. of Clin. Med., 
1902, No. 3. 

62 Am. Jour. Med. Sci., September, 1902, vol. exxiv. 
34 



530 



CLINICAL DIAGNOSIS 



was 26,300, six hours after the operation. The nature of the opera- 
tion seemed to have little influence on the count, yet the height of the 
rise is roughly parallel to its extent and character. The highest count 
was in a nephrotomy, 32,000 cells. King found in no case a rise of 
20,000. There is little relation between it and the post-operative fever. 
Chloroform anaesthesia can cause a true leucocytosis, but this is very 
transitory indeed ; ether none. 

In point of degree there is no sharp line between the leucocytosis 
of infected and non-infected wound repair, but the latter is on the 
wane at a time when the former is just beginning. 

When a packing is changed the leucocytes may rise somewhat. In 
a closed wound the leucocytes are a good index of an infection. 

The diseases causing, as a rule, no leucocytosis are typhoid fever 
(page 599), measles (page 594), and tuberculosis (page 596). 

Pseudoleucocytosis. — Certain other blood-changes occur in much 
the same conditions and are supposed to have the same significance 
as a leucocytosis. Among these are iodophilia (page 537) and a rela- 
tive increase of the polymorphonuclear neutrophiles while the total 
count does not rise above normal. This is seen in cancer, septicaemia, 
etc.. Also degenerations of the leucocytes, fragmentation of the nuclei, 
as in cancer, the appearance of myelocytes, etc., have much the same 
significance. 

Leucocytosis of Malignant Tumors. — Cases of carcinoma (page 
612) and sarcoma (page 615), while not always, frequently present 
a leucocytosis. This bears no relation to> the kind of tumor, except 
that it occurs more commonly with sarcomata than carcinomata. 
There is none in epithelioma of the skin, while in the case of some 
organs, for instance gastric carcinoma, it is common. On the whole 
it bears no relation to the situation of the tumor. The blood of a case 
of sarcoma has been described as even simulating a leukaemia. It is 
a leucocytosis of polymorphonuclear cells, and mononuclears in some 
cases as well, which disappears after the removal of the tumor. The 
occurrence of the leucocytosis in these cases is so variable that it cer- 
tainly is not alone the presence, nature, or situation of the tumor 
which determines it. 

Post-Hemorrhagic Leucocytosis. — After a large hemorrhage there is 
a rise of the leucocytes which begins in from ten to fifteen minutes, 
and in one hour reaches about 16,000 to 18,000. This lasts a few days 
and then disappears. It is an increase of the polymorphonuclear neu- 
trophile cells. The cause cannot be a new production of cells, since it 
begins so suddenly ; it is best explained by the tissue lymph which 
flows into the vessels in order to restore the volume of blood, carry- 
ing with it a large number of white cells. Many consider that the 
nature of the wound is important, since often with injury and without 



THE BLOOD : LEUCOCYTOSIS 



531 



hemorrhage there is a leucocytosis, while if the hemorrhage be the 
result of a very slight injury, as, for instance, that from a gastric 
ulcer, the duration of the leucocytosis is very brief, lasting in some 
instances but two days. Stassano and Billou 53 found that leucopenia 
followed severe hemorrhages; a true leucocytosis smaller hemorrhages. 

In a case of cirrhosis of the liver with fatal hemorrhage from the stomach, 
before death the reds were 1,960,000, haemoglobin 23 per cent., leucocytes 23,000. 

Agonal Leucocytosis.— Belief in an agonal leucocytosis existed be- 
fore the inflammatory leucocytoses were understood, and hence many 
cases may have been those of terminal pneumonia. Yet this does not 
explain all of the high counts at the last of a disease. Cabot's case, 
for instance, of pernicious anaemia resembled a leukaemia. Such cases 
are rare, it is true. In most diseases the leucocytes do not change or 
even drop at death, while in some cases they do rise, which Ehrlich 
ascribes to the slowing of the circulation and hence the accumulation 
of the leucocytes along the periphery of the blood-vessels. Arneth 
doubts an agonal leucocytosis, thinking the leucocytoses which occur 
then are easily explained by the disease causing death. 

Medicinal Leucocytosis. — After the administration of any of a long- 
list of drugs, including the ethereal oils, tonics, myrrh, turpentine, 
peppermint, whether by mouth or subcutaneously, there may result 
a considerable rise of the leucocytes. In the case of the drug by mouth 
it seems to be comparable to a digestion leucocytosis, while in the case 
of subcutaneous injection the local reaction also may be important. 
The list of these drugs is so long and varied that an enumeration is 
not valuable. It is interesting that the extracts of certain body tissues 
and organs seem positively chemotactic. 

The reverse is also true, as in the case of blood poisons which de- 
stroy the cells, hence with phenacetin, the chlorates, and pyrogallic 
acid there is even a drop. 

Other Causes. — In the case of animals simple violence will cause a 
rise of the leucocytes. In man, hard work, severe sweat, heat and cold, 
will also; many vasomotor influences, slowing of the circulation, as 
for instance by cold, Thayer finding in typhoid fever that a cold bath, 
especially those leaving the patient shivering, would raise the count 
about 6000 cells ; the formula remained the same. 54 In any cyanotic 
part the leucocytes are increased. 

Violent exercise will cause leucocytosis, as was seen in the run- 
ners of a twenty-five mile race whose leucocytes rose from 14,000 to 

22,000. 55 

65 Compt.-rend. Soc. Biol., 55, p. 180. 

54 See also Becker, Deut. Arch. f. klin. Med., 1001. 

95 Larrabee, Jour, of Med. Research, 1902, vol. ii. 



532 



CLINICAL DIAGNOSIS 



Mixed Leucocytosis. — By this is meant an increase of amoeboid 
and non-amoeboid cells, that is, of granular and non-granular; but as 
commonly used it means the presence in a leucocytosis of neutrophile 
myelocytes. The best known condition is in leukaemia, in which the 
absolute number of myelocytes may be from 50,000 to 100,000. In 
no other condition does the absolute number of myelocytes rise above 
1000 (Ehrlich). Leukaemia is the chief condition in which the eosino- 
phile myelocytes are found, and where Mastzellen are increased. All 
forms of non-granular cells are also increased. The next most im- 
portant condition is pernicious anaemia. Almost any leucocytosis 
could be called mixed, since the higher the count the younger are the 
forms which appear in the blood. In these cases myelocytes have no 
significance if they disappear as the count falls, but should they remain 
after the count sinks it means exhaustion of the bone-marrow (that is, 
if the septic features continue). The appearance of myelocytes in 
those conditions means more, 56 provided we grant that the leucopenia 
of such cases (typhoid fever, e.g.) is proof of the inhibiting action of 
the bacterial toxine on the marrow, which is by no means certain. 

In cancer of the bone-marrow, sarcoma, and metastatic carcinoma, 
there is a mixed leucocytosis which some suppose is due to the nega- 
tive chemo taxis of the tumor. In severe post-hemorrhagic anaemias 
and in various children's diseases, especially diphtheria, anaemia, 
rickets, congenital lues, and pneumonia just after the crisis, it also 
occurs. 

Mastzell Leucocytosis. — The only condition in which these cells 
are increased in the blood is splenomyelogenous leukaemia, in which 
case they may be even 15 or 20 per cent, of the increased count. 
Isolated cases, as of cancer, septic bone disease, various skin dis- 
eases, and even chlorosis, have been reported. 

Increase in Large Mononuclears. — The origin of these cells is un- 
known. They are increased absolutely in typhoid fever, post-febrile 
measles, and especially in malaria in which they are in large numbers, 
even 20 to 30 per cent, of an almost normal count, a point of diag- 
nostic value. 

Lymphocytosis. — Ehrlich classified increased leucocyte counts as 
active, passive, and mixed leucocytoses. A true leucocytosis is 
active because amoeboid cells are increased which are supposed to have 
wandered out into the circulation in response to a positive chemotactic 
agent. A lymphocytosis he called passive since he supposed these cells 
to be mechanically washed out of the lymphatic tissue. 

That some lymphocytes are amoeboid on a rather hot stage (44 0 to 46° C.) is 
granted ; that they can migrate into the tissues in certain skin diseases is also 

53 Schindler, Zeits. f. klin. Med., 1904, Bd. 54, p. 512. 



THE BLOOD : LYMPHOCYTOSIS 



533 



granted ; they may be the cells of a pleural exudate ; yet there is little resemblance 
between the true leucocytosis and the lymphocytosis which would lead us to call 
the latter active. 

The term lymphocytosis always refers to the absolute number of 
these cells, not to their percentage. 

Physiologically the condition exists in infants, and during a di- 
gestive leucocytosis. Pathologically it occurs in simple gastrointes- 
tinal disturbances of children (page 608), in whooping-cough (page 
526), in cervical adenitis, during the reaction to tuberculin, in malig- 
nant lymphomata, and in sarcoma multiplex cutis. The best illustra- 
tion is lymphatic leukaemia, in which case over 90 per cent, of the 
140,000 cells may be small mononuclears. There is an absolute in- 
crease in splenomyelogenous leukaemia, and after splenectomy there is 
very constantly a slow increase of lymphocytes to. even twice the nor- 
mal number, which begins in about a- month and continues during the 
first year. The blood picture may even suggest a leukaemia. The 
same, but to a less degree, occurs in chronic spleen tumor. 

The leucocyte count may be low and yet a true lymphocytosis exist, 
as in a recent case of amoebic dysentery, with a- count of 2500 cells, 
68 per cent, of which were small mononuclears. The best illustrations 
among the chronic diseases are hereditary lues- and severe rickets. 
The statement is usually made that in chlorosis, pernicious anaemia, 
debility, late typhoid, Graves's diseases, haemophilia, scurvy, and 
during thyroid treatment there is a lymphocytosis, but in many of 
these cases the increase was not true but relative, since the granular 
cells were diminished. 

The leucocytosis of children is sometimes a marked lymphocytosis, 
as in the case with enlarged tonsils mentioned by Churchill, in which 
the count was 20,000, 70 per cent, of which were small mononuclears. 
In the diagnosis of lymphatic leukaemia these cases must be remem- 
bered. The clinical microscopist must also remember that there is 
almost no apparent relationship between enlarged lymph-glands and 
lymphocytosis, as is seen in Hodgkin's disease, chronic, and acute 
lymphatic leukaemia. 

Ehrlich mentioned an interesting case of general lymphosarcoma 
with but 0.6 per cent, of small mononuclears in the blood. 

Leucopenia may result from the reduction in one group of cells 
or from a general reduction of all. The former is seen during typhoid 
fever. Below 5000 cells per cubic millimetre is usually considered a 
leucopenia. Leucopenia is said to be the first step in a leucocytosis. 
The drop in the count is thought to be due to the disintegration of 
some and the accumulation of other white cells in the internal organs, 
and the subsequent rise to the emptying of the depots of cells. In 
tuberculosis of lymph-glands the count is even below 600 cells. 



534 



CLINICAL DIAGNOSIS 



Cases of leucopenia have been reported under the name " alymph- 
aemic lymphomatosis." For instance, a case (Schwartz) with fever and 
acutely swollen glands, had only 600 leucocytes per cubic millimetre, 
and they all lymphocytes (no autopsy). Tiirk said some of these 
cases show none of the features of an infection. 

The relationship between abdominal troubles and leucopenia is 
interesting. Typhoid is a disease with leucopenia while limited to 
the intestine, with leucocytosis when other organs are involved ; tuber- 
culous peritonitis uniformly causes no leucocytosis; "abdominal in- 
fluenza " causes no leucocytosis. 

Following some fevers the count is low. At the end of typhoid 
it is often but 2000 cells. In a recent case of hemoglobinuria the 
count of leucocytes ran nearly parallel to that of the red cells, with, 
at the lowest, 2,500,000 reds and 950 leucocytes. 

In cases of starvation or malnutrition due to any cause the count 
is low; for example, voluntary starvation (page 523), or that due to 
disease as cancer of the oesophagus (page 620). In one of our cases 
of ulcerative colitis the patient's red count was 2,100,000, and the 
leucocytes 700 per cubic millimetre. 

In acute miliary tuberculosis (page 598) the counts are very low 
sometimes, with a great reduction of young cells. In all chronic intoxi- 
cations, alcohol, morphia, lead, ether, mercury, arsenic (hence the 
drop in leukaemia?), leucopenia is the rule. 

Eosinophilia. — By eosinophilia is meant an absolute increase of 
the eosinophile cells. The average percentage in a normal case is from 
2 to 4 per cent., and while often it is the percentage by which the 
eosinophilia is judged the term should be limited to those cases in 
which the absolute number of these cells is above 250 per cubic 
millimetre. 

Those conditions in which these cells are increased vary so much 
that they are well termed the most capricious cell of the blood. 

1. There is a physiological eosinophilia during childhood. 

II. Diseases of the Haematopoietic Organs. I. Bone-Marrow. — (a) 
Splenomyelogenous leukcemia is a diagnosis which Ehrlich says should 
be made only in case there is absolute increase of these cells. As a 
rule, they are much increased, even to 29,000 per cubic millimetre 
(Zappert). The number of undoubted cases, however, is increasing 
in which these cells are very few or, indeed, entirely absent. 

(b) In sarcoma of the bone-marrow they are sometimes present 
in great numbers (page 615). In (c) osteomyelitis and (d) osteo- 
malacia they are sometimes increased. 

2. Spleen. — One year after extirpation of the spleen there slowly 
develops an eosinophilia which lasts for several months. These cells are 
increased to from thirty to fifty times their normal number, and may 



THE BLOOD: EOSINOPHILS 



535 



constitute even 36.6 per cent, of the leucocytes. A somewhat similar 
condition is present in cases of chronically enlarged spleen, in which 
the percentage of these leucocytes may be from 7 to 12, and in new 
growths of the spleen. Possibly these spleens are functionless. 

3. Lymph-Glands. — That an eosinophilia may be due to disease 
of these glands is not certain. Cases of carcinoma have been cited, 
but metastases to bones have not been excluded. In one case with 
such metastases the eosinophile cells numbered 60,000. 

III. Asthma. — In true bronchial asthma at the time of the par- 
oxysm eosinophile cells may be from 10 to 20 per cent, of the leuco- 
cytes ; in one case of Billings, between 53 and 54 per cent. This is of 
diagnostic importance in excluding asthmatic attacks due to other 
cause. In emphysema these cells are also increased, in one case being 
53.6 per cent, of a total of 8300 leucocytes. 

IV. Skin Diseases. — A large number of skin diseases are accompa- 
nied by eosinophilia. This depends more upon the extent of the lesion 
than its nature. The contents of the pustules are sometimes interest- 
ing, since all of the leucocytes are eosinophiles. 

In one case of pemphigus reported by Zappert there were 4800 eosinophiles 
per cubic millimetre of blood ; in one of pemphigus vegetans in this clinic on one 
day, with a total of 20,400 leucocytes, 2.6 per cent, were eosinophiles ; on another 
day, 1 1.6 per cent. ; in pellagra and psoriasis these cells are sometimes increased; in 
urticaria they may reach even 60 per cent, of the total number ; in a case of pur- 
pura, with cyanosis in this clinic, of 52,000 leucocytes, n per cent, and later, with 
almost as high a count, 25 per cent, were these ; in certain cases of eczema they 
are increased ; of two cases of scleroderma in this clinic, in one they constituted 
2.4 per cent, of 7000 leucocytes ; in the other, 3.3 per cent, of 10,500 ; in five cases 
of purpura simplex the red cells and haemoglobin were practically normal ; three 
had a leucocytosis of from 10,100 to 40,600 (eosinophiles, 12. 1 per cent.). This 
last case was also one of myositis with the eosinophile cells running from 11.3 to 
25.6 per cent, (total leucocytes 20,300), but no other evidence of trichinosis could 
be found. In one of three cases of purpura rheumatica there was a leucocytosis 
of 13,300. In three cases of Henoch's purpura the leucocytes in one were 10,000. 
In two cases of purpura hemorrhagica the leucocytes numbered 7500 and 6600 ; of 
the latter 4.5 per cent, were eosinophiles. In one case of purpura hemorrhagica 
9.4 per cent, of the 5200 leucocytes were eosinophiles. In one case of morbus 
errorum the leucocytes were 5000, the eosinophiles 18 per cent. ; they slowly 
diminished for four counts during one month when in the hospital, at which time 
they reached normal. After chemical irritation of the skin, for instance by mer- 
curic chloride, these cells are much increased, even to 14 per cent. 

V. Parasites. — Any parasite, from the harmless pin-worm to the 
most malignant uncinaria, may cause an eosinophilia. It is not always 
present, nor does its degree bear any relation to the severity of the in- 
fection or the danger of the parasite. Amberg in amoebic dysentery 
of children found a slight eosinophilia. 

In trichinosis, Brown demonstrated this as a most important point 
in diagnosis, the maximum count being a total of 35,000 leucocytes, 
68.2 per cent, of which were eosinophiles. This eosinophilia is not 



536 



CLINICAL DIAGNOSIS 



always present, as in a case reported by Howard and another by Da 
Costa, but it was present in all the other 25 or 30 cases that have been 
reported. In Gwynn's case they were 65.9 per cent. In Brown's 
case they were high and fell gradually. The neutrophile cells are 
relatively and absolutely low. Brown was unable to get any Charcot- 
Leyden crystals from the blood, hence considers some other element 
than this necessary for their formation. 

In uncinariasis the eosinophile cells have constituted usually from 
8.2 to 10 per cent, in one case reaching 72 per cent, of the count. 
Our highest count was 13 per cent, in a total of 7400 leucocytes. 
In one case with Taenia saginata the eosinophile cells were 34 per cent. ; 
of Ascaris lumbricoides, 19 per cent. ; Oxyuris, 16 per cent. ; Strongy- 
loides intestinalis, 13,5 per cent.; Bilharzia, 20 per cent. In filariasis 
they vary from 4 to 17 per cent. ; in Calvert's case, they were 22 per 
cent., and reached a maximum at day (in others at night). Calvert 
thinks that the number of eosinophile cells depends upon the acuteness 
of the attack, and so in long-standing cases there may be no increase. 
He found that the number of these cells in the circulation bears an 
inverse relation to the number of embryos, the former increasing dur- 
ing the day when the embryos disappear. In hydatid cysts of the liver 
an eosinophilia is considered important. It varies from 7 to 20 per 
cent., and in one case reached 40 per cent. During the afebrile stage 
of malaria these cells have risen to 20.4 per cent. In dracontiasis 
they are reported as from 6.4 to 36.6 per cent. 

VI. — A post-febrile eosinophilia occurs after most fevers, or at least 
these cells increase to the upper limits of normal. In scarlet fever 
during the course these cells may vary from 8 to 15 per cent., but in 
all other fevers during the height they are diminished, and as the 
temperature drops they rise ; in pneumonia, for example, they may 
rise to 5.7 per cent., absolute number, 430; in acute articular rheuma- 
tism, to 9.4 per cent., absolute number, 970; in malaria one clay after 
the chill, to 20.34 per cent., or i486; in varicella, to 16 per cent; 
in measles, to 5 per cent. ; and in rickets, to 20 per cent. 

VII. — During a positive tuberculin reaction these cells may fall and 
then rise even to 26.9 per cent. (3220). In one case reported by 
Grawitz their absolute number was 41,000 of a total of 45,000. 

VIII. — In diseases of the genital organs these cells are often in- 
creased; in all ovarian diseases except cancer; in ten of eighteen 
ovarian cysts and abscesses; and in gonorrhoea, especially posterior 
urethritis and prostatitis. 

IX. — In malignant disease they sometimes constitute from 7 to 10 
per cent, of the leucocytes, and in one case of lymphosarcoma the} 7 
numbered 60,000 cells. 

X. — After certain medicines, as camphor (to 9 per cent.) or the 



THE BLOOD: IODOPHILIA 



537 



inhalation of carbon dioxide they rise, although this increase is incon- 
stant and rare. 

XL — In diseases of the sympathetic nervous system. 

The origin of eosinophilia does not concern the clinical microscopist. He no- 
tices that in certain smears from vesicles he finds large numbers of these cells, and 
that in those conditions with local accumulation the count in the blood is usually 
normal. There is a group of rare cases with certain cells increased in the blood 
concerning which it is a matter of opinion whether they are eosinophiles or neutro- 
philes. Were this the experience of one or two men their technique or their judg- 
ment might be exposed to criticism, but enough now have found this difficulty to 
justify the statement that in some cases, rare, it is true, there is a cell the 
characteristics of which are intermediate. Such occurs in trichinosis especially. 
(See page 504.) 

Iodophilia. — The iodine reaction of leucocytes is tested with the 
following reagent : Iodine, 1 gm. ; potassium iodide, 3 gms. ; water, 
100 cc. ; gum-arabic, 5 gm. 

A drop of this reagent is put on a slide, a fresh unfixed smear 
on a cover-glass is pressed down onto it, and the excess of stain then 
removed by pressure on the glass. 

All the blood elements are stained a bright yellow, but in certain 
conditions some of the polymorphonuclear neutrophiles are found to 
contain granules which take a brownish-red color ; some cells are 
diffusely stained; similarly staining substance is seen in the 
plasma. 

The granules within the cells (the intracellular reaction) vary 
much in size, shape, color, number, and arrangement, or the substance 
may be diffusely present in the cell. The masses in the plasma (the 
extracellular reaction) are round or oval (from 2 to 8 microns in 
diameter), and often suggest masses deposited from disintegrated 
cells. 

In judging the degree of the test, both intensity and number of 
cells affected are to be considered. 

Why the test is given, what it means, is very uncertain. The 
substance present is supposed to be glycogen, but since all normal 
leucocytes contain this substance, it must be present here in some 
particular form. 

The reaction is positive in the greatest variety of conditions; in 
pernicious anaemia, in severe secondary anaemia, but not in chlorosis, 
and the moderate grades of anaemia ; it is always positive in leukaemia. 
The number of cells bears a direct relation to the acuteness of the 
attack, and it is said has a prognostic value. La Franca found them 
in chlorosis, and considered only a large number of affected cells im- 
portant. Locke considers it a test independent of, but of nearly 
equal value with, leukocytosis. It is positive in nearly all cases of sep- 
ticaemia, especially those with leucocytosis, in cases with purulent 



538 



CLINICAL DIAGNOSIS 



exudates, hence especially pneumonia. It is invariably present in 
severe septic conditions (Locke). 57 

A clinical importance is claimed for the reaction in certain dis- 
eases, as in appendicitis. Locke found the intensity of reaction to 
depend on the severity and duration of the process in the appendix 
and the amount of septic absorption from the focus. But the point 
of greatest importance is, he claims, the occurrence of a marked iodine 
reaction without leucocytosis in some of the most virulent cases. After 
operation with free drainage the reaction disappears within forty- 
eight hours. 

The pendulum has swung in regard to the value of this test, and 
many now: condemn it as of little value surgically (Reich). Kiittner 
gives it some prognostic value, an increase in intensity of the reaction 
being a bad sign. 

The gynaecologists claim its presence to be of value in the diagnosis 
of pelvic abscess. In cases of ovarian cyst with twisted pedicle the 
test is negative, even though there is a high leucocytosis. The same 
is true of other conditions without pus formation. 

Blood Platelets. — Blutplatchen, Plaques (Kemp, Osier), Haemato- 
blasts (Hayem), (Plate II, 23). In the blood are the so-called 
" third corpuscles," small colorless bodies containing no haemoglobin, 
about three microns in diameter, round, oval, or rod-shaped, according 
to the view-point, without a biconcavity, bluish, soft, homogeneous 
or granular, but not sticky and glistening when perfectly fresh as 
they are so soon after, which look and stain like nuclear material; 
they contain no nucleus, no membrane, and have in an ordinary fresh 
blood preparation a peculiar bluish refractivity like the protoplasm of 
a non-granular leucocyte. Platelets when perfectly fresh are slightly 
granular, but at once when removed from the blood-vessel become hya- 
line and glassy, then pale, and disappear, or unite to form a granular 
mass. Tw;o important characteristics are to be emphasized. A plate- 
let soon becomes a very sticky body, and unless special fixing fluids are 
used it attaches itself at once to the glass, to other corpuscles, or the 
platelets collect in masses of from two to hundreds. The other char- 
acteristic is its fragility, for it disintegrates rapidly, even in a few 
seconds. This disintegration is seen to best advantage in the masses 
of platelets, and the result is the so-called Schultze's " granular 
masses" (see Fig. 114), from the periphery of which radiate fibrin 
strands, and at the edges of which are vacuole-like areas, the so-called 
" viscous metamorphosis " of Eberth, or the " mucoid degeneration " 
of Osier. 

Stained with the usual Romanowski mixtures, they are seen nor- 
mally in groups of one to ten ; they would seem to be composed of 
57 Jour. Med. Research, January, 1902. 



THE BLOOD: PLATELETS 



539 



nucleus and protoplasm, the nucleus consisting of rows of blue or 
reddish dots sometimes arranged in a spherical mass, the protoplasm- 
like substance sometimes hardly seen, sometimes 
swollen to give them almost the size of a red cor- Y«^K I J^liV/' 
puscle. 58 f • <^ 

When the platelets rest on cells they resemble ( b Q '%f^^ 
malaria parasites. It is to be noted that they have FlG> II4 _ Platelets (copied 
not the definite structure of the parasite, that they from Osier): a, platelets in ir- 
are surrounded by a clear zone from which the ~%^lf g ™„- 
haemoglobin has been pressed out by the platelet, larmass. 
while the protoplasm of the corpuscle comes up exactly to the para- 
site. 

Their size in the fresh specimens varies from 2.5 to 5 microns 
in diameter (Determann) ; 1.5 to 3.2 microns (Osier) ; 2 to 7 microns 
(Preisich and Heim). In general their size varies inversely as their 
number; that is, the more the platelets the smaller they are. Their 
fragility also is more marked when they are increased. Some soon 
show clear areas, either in the centre or or one side, or on the whole 
periphery; others become crescents, triangles, quadrangles, spindles, 
threads, etc. (see Fig. 114, a, b). It is much the best to study them 
at a temperature not over 40 0 F., for then these changes are much 
slower, requiring minutes instead of seconds. 

It is customary to call anything a platelet which is smaller than a 
red blood-cell and which does not contain haemoglobin. This is a 
mistake for the blood certainly contains cell detritus, and the term 
" platelet " should be reserved for bodies which have a peculiar bluish 
refractility, are very sticky, and which soon go to pieces. Anything 
floating in the plasma in a blood preparation to which a fixing fluid 
has not been added is probably not a platelet, although it may resemble 
it perfectly. Buds from red cells lose their haemoglobin, become gran- 
ular or glassy, "and cannot then be told from platelets;" "inner 
bodies " extruded from red cells, after undergoing certain degenerative 
changes, " cannot be told from (degenerated) platelets." One must 
decide whether he will term platelets all fragments which look like 
degenerated platelets. The question is simple when we are studying 
only perfect cells. It is difficult when we are counting degenerated 
platelets. 

Specimens of the platelets are best obtained in the following 
manner: A drop of .Picini's fluid (mercuric bichloride, 2; sodium 
chloride, 4; glycerin, 26; water, distilled, 226), or Hayem's fluid 
(water, 200 cc. ; sodium chloride, 1 gm. ; sodium sulphate, 5 gms. ; 
potassium iodide solution [water, 100, potassium iodide, 5, iodine in 
excess], 35 cc), or the fluid recommended by Kemp (0.9 per cent. 

58 See also Puchberger, Virchow's Arch., 1903, vol. clxxi. p. 181. 



540 



CLINICAL DIAGNOSIS 



sodium chloride solution in 2.5 per cent, formalin), or Determann's 
fluid (distilled water, 160; glycerin, 30; sodium chloride, 1; sodium 
sulphate, 8; methyl violet, 0.025 parts). The best fluid, however, is 
a 10 per cent, sodium metaphosphate solution. A drop of the fluid is 
placed on the well-cleaned tip of the finger; the skin is then pricked 
through this drop so that the blood will at once mix with the fixing 
fluid ; a drop is then placed on a slide and covered with a cover-glass. 

To count the platelets, the relation between them and the red 
blood-cells is counted in a fresh preparation. An ordinary red blood- 
count is then made, and from this the number of platelets per cubic 
millimetre may be easily calculated. Helber 59 counts them directly. 
The blood is quickly mixed with 10 per cent, sodium metaphosphate 
in a pipette giving a dilution of 1 : 30, and is then counted on a ruled 
slide similar to the ordinary counting-chamber, save that the thick- 
ness of blood-film is 0.02 mm. 

The normal number per cubic millimetre has been found 250,- 
000 (Osier); 225,000 (Determann) ; 245,000 (Enden). Yet the 
number varies much in the same person at different hours of the 
day, and in general the physiological variations are so considerable 
that only very great ones are to be considered clinically important. 
But Helber found no great daily variation (190,000 to 260,000;. 
average 228,000. The remarkable closeness of these average fig- 
ures is interesting). In the new-born for the first few days they are 
very few. In certain diseases they are very many; in other diseases 
very scarce. It is hard to classify these diseases, but most agree that 
they are increased in anaemias due to any cause, especially post-hemor- 
rhagic, during the blood regeneration, and may be related to the 
red blood-cells as 1 : 10; the increase is surely a good sign; they are 
increased in chlorosis, decreased in pernicious anaemia and in any- 
severe anaemia which is doing poorly. The greatest increase is in 
splenomyelogenous leukaemia, very low counts in lymphatic (Pratt). 
They are increased in chronic diseases with cachexia, and in condi- 
tions with malnutrition generally, the blood showing the marked 
changes of hydraemia, low specific gravity, poikilocytes, etc. The 
number of the platelets varies with the amount that the disease affects 
the blood, hence there are more in cancer and in nephritis than in the 
anaemia due to cardiac disease, tuberculosis, etc. 

During acute fevers of long duration they are at first diminished, 
but increased during the third or fourth week as the patient begins to 
get weak. In typhoid fever a rapid diminution is considered a bad 
sign (Turk). In short sharp fevers there is at first a decrease, then a 
reactionary increase, the curve often resembling that of the leucocytes. 
The more acute, more severe, more threatening the disease, the higher 
59 Deutsch. Arch. f. klin. Med., 1904, Bd. 81, p. 316. 



THE BLOOD: PLATELETS 



541 



the temperature, the fewer the platelets, so that in malaria and pneu- 
monia not one may be found. After the temperature drops, especially 
if by crisis, the platelets may rise above normal in twenty-four hours 
and continue so for two to three days, then return to normal. In 
erysipelas and septicaemia there is no preliminary decrease, but an 
increase from the start. In acute articular rheumatism there is a great 
increase. 

Cases reported with total absence were a moribund case of pneu- 
monia and one of nephritis, a case of pernicious anaemia and one of 
purpura. 

Pratt 60 found no relation to exist between the coagulation time and 
platelet count. 

The meaning of the platelets has been much disputed. Donne considered 
them "globulins;" Schultze, fragments of broken-down leucocytes (also Howell) ; 
Bizzozero said they were independent corpuscles, a view which Dr. Osier also 
holds ; Lowit said, artefacts ; Hayem is the only one who considers them as very 
young red blood-cells. For several years the belief in these as independent cor- 
puscles was held, until in 1897 Arnold taught that they were fragments constricted 
from red blood-cells or fragments of cells which had gone to pieces. Determann, 
following this work, pointed out that their number was usually increased in the 
same proportion that the red blood-cells showed signs of degeneration, that their 
fragility and their size depended on their number ; he considered them merely a 
measure of the resistance of the red cells (Mosso). Schwalbe, Miiller, et al., 
consider this platelet formation from red cells a necessary preliminary step in 
coagulation. 

Maximow 61 considers them the extruded inner body of the nucleoid. In speci- 
mens properly stained (Maximow used methylene blue and eosin, hence any of 
the modified Romanowski stains will do) all steps of this process can be found. 
Some cells have a blue-stained centre; in others this blue body projects from the 
cell ; again it lies in a depression on the edge of the cell ; others lie free. Some- 
times the cell looks like a bomb bursting and discharging this mass. Engel thinks 
these masses are remnants of the nucleus, Maximow says not. Preisich is one of 
the last to insist that they are the extruded nuclei of the red blood-cells, hence are 
in constant process of formation ; that animals with nucleated reds have no plate- 
lets ; that platelets increase as the reds increase, and (this point is hardest to 
accept) that eosinophile leucocytes are white phagocytes which have ingested 
platelets. 

On the other hand, platelets occur in greatest numbers where the polymorpho- 
nuclears are breaking down, as in splenomyelogenous leukaemia, and when a leuco- 
cytosis is subsiding; and least where these cells are the least numerous, as in 
pernicious anaemia, lymphatic leukaemia, et al. 

The next work of importance is that of Deetjen, 62 who, using a special agar 
plate, considers that he has proved them independent cells, motile, and nucleated. 

Deetjen's method is as follows: Five grammes of agar agar are boiled in 500 
cc. of distilled water for thirty minutes to dissolve it, then filtered through a folded 
filter. To each 100 cc. of filtrate are added 0.6 gm. of sodium chloride, 6 to 8 cc. 
of 10 per cent, sodium metaphosphate (NaPOs), and 5 cc. of 10 per cent, acid 
potassium phosphate (KoHPO*). After adding these salts the fluid should not be 
boiled nor much heated, lest the metaphosphate be converted to orthophosphate. 
The solution should now be clear. A drop is placed on a slide and allowed to cool. 

60 Jour, of Med. Research, August, 1903. 

61 Arch. f. Anatomie u. Physiologie, Anat, Abth. 1899. 
62 Virch. Arch., May, 1901, vol. clxii. 



542 



CLINICAL DIAGNOSIS 



The most of the agar surface is cut away, leaving a smooth area about 2 mm. 
square. On this the blood-drop is placed and at once covered by a cover-glass. 

The specimens may be fixed by allowing i per cent, osmic acid to run under 
the slip; the cover is then raised, washed in water, then in 96 per cent, alcohol 
for one minute, then stained in hematoxylin and eosin. 

Deetjen believes them to be actively amoeboid, the amoeboid motion requiring 
the above salts for its best demonstration. In such agar specimens they are round 
or elliptical disks, then in one or two minutes show a more refractive round inner 
body with a greenish tinge and a periphery of pale protoplasm which is " in active 
motion," changing shape so rapidly, and position as well, that it is hard to draw 
them. This may continue for hours ; best on a warm stage. The stained specimens 
show the protoplasm and the inner body which takes a nuclear stain, and seems 
to consist of a chromatin net-work. The ease with which this can be seen depends 
on the amount they have " spread out." Some are larger than red blood-cells. 

Wlassow, who added dilute mercuric chloride solution to fresh blood and 
could see the platelets "leave the. red cells," was an especially severe critic of Deet- 
jen's work, and pointed out that although platelets do change their shape they 
never resume their original one ; they may extrude " pseudopods," but they never 
show true amoeboid motion ; chloroform will stop the amoeboid motion of leuco- 
cytes, but not that of platelets ; their nucleated structure is not proved ; amoeboid 
motion is never seen in platelets in the circulation; Deetjen uses an agar field, 
which would much favor the production of diffusion currents ; Wlassow, therefore, 
still believes them to arise in the red cells. Wlassow made quickly a fresh specimen 
of blood, then ran under the cover-glass a drop of one-fifth concentrated mercuric 
chloride solution ; at once the reds become granular and a small refractive hyaline 
area appears, usually at the periphery. From this a bud develops which is some- 
times an irregular mass of granules which increases and may become more thorny, 
and then separates from the corpuscle. This body may or may not contain haemo- 
globin, those which do later lose their color and then cannot be distinguished from 
platelets. Others have confirmed Deetjen's work (Dekhuysen and Kopsch). 

We have observed most of the above phenomena, but have seen no true amoe- 
boid motion, that is, a change in position which the changes in shape will explain. 
All look more like mechanical and chemical processes. 

Kemp, in his recent interesting work on the blood at a high altitude, is confident 
some platelets do contain haemoglobin, and hence is in doubt as to their origin; 
formerly he had been a firm believer in them as third corpuscles. 

Reaction of the Blood. — To litmus the blood is alkaline, and 
various methods have been proposed to determine the amount of this 
alkalinity. If by alkalinity is meant a preponderance of free OH-ions 
in the blood, the physical chemists have taught us that the blood is an 
almost neutral fluid, quite so when defibrinated, slightly alkaline when 
arterial, while the serum is almost as neutral as distilled water. But 
by alkalinity the clinical chemist means the acid-combining property 
of this fluid, or the amount of alkali in it which can be substituted 
by an acid. This is of interest and of considerable importance. 

The reaction of the blood is due to the alkaline phosphates of 
sodium and the alkaline earths, and to the alkaloidal bases (Labbe). 
Yet chemically the blood acts as an acid from the presence of acid 
salts ; that is, it contains unstable acid salts which react to color indi- 
cators as feeble bases, but which behave as acids, since, in the presence 
of true alkali, they become neutral. Brandenburg divides the alkaline 
components into two parts. The first is the diffusible alkali, the native, 



THE BLOOD: ALKALINITY 



543 



or the mineral alkali, that is, the bases which are bound to carbon 
dioxide. This is diffusible, and may be measured by bringing the 
blood into contact through a diffusion membrane with alkaline fluids 
of various concentration until one is found which in contact with blood 
does not change its alkalinity. The other, and greater in amount, is 
the alkali- and acid-binding value of the proteids which varies directly 
with the amount of albumin, hence chiefly with the blood-count. The 
diffusible alkali is to the total as i : 5 in the case of the total normal 
blood ; in the serum, as 1 : 2 ; in the corpuscles, as 1:8; and in cases 
of anaemia of various grades that of the total blood may vary from 
1 : 3 to 6. 

The alkaline tension (that is, the diffusible alkali) is rather con- 
stant, about 60 mg. of NaOH per 100 cc. of blood. The total alkalinity 
depends much on the blood-count, and hence is subject to great varia- 
tions. The alkaline tension and the molecular concentration of the 
plasma run almost parallel. 

The alkaline tension has been found reduced in diabetes mellitus, in 
uraemic coma, in pneumonia, and in certain cases of nephritis (small 
contracted kidney and acute toxic nephritis). These cases, then, may 
be said to show " acidosis," or evidence of acid intoxication. 

The alkalinity of the blood can be varied for a short time by alkaline 
drugs, and alkaline rectal enemata, but the effect is very temporary. 

Determination of the Alkalinity. — There is hardly a determination 
which the clinician would more gladly make than the alkalinity of the 
blood. It would be of such importance in diagnosis, in prognosis, and 
in therapy ; and yet the methods are notoriously inexact. 

The reaction of the blood to litmus has little absolute value, since 
it does not show the carbon dioxide the chief acid of the blood, and 
yet this is the indicator which has been commonly used, and the results 
obtained have a certain empirical value. 

(1) Landois-v. Jaksch Method. — By this method it is attempted to determine 
the alkalinity of the plasma by adding to the blood an acid solution of Glauber's 
salt of such composition that the blood is not laked. Eighteen mixtures of this 
solution are used. 

Solution 1 : 1 cc. contains 0.9 hundredth-normal tartaric acid and 0.1 cc. 
cone. Glauber's salt solution. 

Solution 2 : 1 cc. contains 0.8 hundredth-normal tartaric acid and 0.2 cc. 
cone. Glauber's salt solution. 

Solution 3 : 1 cc. contains 0.7 hundredth-normal tartaric acid and 0.3 cc. 
cone. Glauber's salt solution. 

Solutions 4 to 9: this series continued. 

Solution 10: contains 0.9 thousandth-normal tartaric acid and 0.1 cc. cone. 
Glauber's salt solution, etc. 

Solution 1 equals 360 mg. NaOH in 100 cc. of blood. Of these various fluids, 
1 cc. is measured into small receptacles, and 0.1 cc. of blood, accurately measured, 
added, mixed, and the reaction tested at once, that is, in less than one and a half 
minutes, with litmus paper. V. Jaksch, who has used this method extensively, 



544 



CLINICAL DIAGNOSIS 



considers that in 100 cc. of blood is alkali equal to 0.26 to 0.30 gm. NaOH. This 
method, although valuable results have been obtained with it, is unsatisfactory 
since the error from disregarding the corpuscles is great. 

Tenth-normal tartaric acid contains 7.5 gms. of the pure acid per litre of water. 
From this the other strengths are easily made. 

Lowy Method. — This is still the best method for the total alkalin- 
ity of the blood. In a special flask, on the neck of which are marks 
indicating 45 and 50 cc, are measured 45 cc. of 0.25 ammonium oxalate. 
To this are added 5 cc. of blood removed by hypodermic syringe from 
a vein of the forearm. The blood is therefore laked and will not 
coagulate, hence the alkalinity determined is that of the total blood. 
This fluid is then titrated with twenty-fifth-normal tartaric acid, lac- 
moid paper saturated with magnesium sulphate as indicator. By this 
method 100 cc. of blood contain from 400 to 600 mg. of sodium 
hydroxide (Strauss, 300 to 350). 

Lacmoid is a product of resorcin, hence is allied to litmus. It is prepared by 
heating gradually to no° C. a mixture of 100 parts of resorcin, 5 of sodium nitrite, 
and 5 of water ; after the violent reaction subsides it is heated to 120 0 C. until 
evolution of ammonia ceases. The residue is dissolved in warm water and the 
lacmoid precipitated by hydrochloric acid. The precipitate should be dissolved and 
reprecipitated several times to purify it, then washed free from acid and dried. It 
is then dissolved, 3 gms. per litre, in dilute alcohol. The paper is dipped in this 
solution, then dried. 

With litmus Orlowski found the alkalinity to be 240 to 267 mg. 
NaOH; with lacmoid 269 to 289 mg. (Engel method). 

The Engel apparatus is based on the Lowy principle, but requires a much 
smaller amount of blood, not much more than for a blood-count. A similar blood 
mixing pipette is used in which the blood., is measured and laked, then titrated as 
above. 

Dare's Method. — Dare has introduced an entirely new method. 
To avoid color-tests, which are confused by the haemoglobin, he deter- 
mines the point at which the absorption bands of the spectrum of 
oxyhemoglobin disappear in a mixture of blood to which amounts 
of tartaric acid are successively added. The apparatus consists of a 
hand spectroscope, a pipette which measures 20 cmm. of blood, and 
a graduated test-tube. In the test-tube are placed a few drops of 
water, into which the blood is washed from the pipette with distilled 
water and more is added until the well-mixed diluted blood just 
reaches the zero point. The two-hundredth-nQrmal tartaric acid solu- 
tion is then added. 

Tartaric acid (pure), 0.075 gm. dissolved in distilled water; alcohol (95 per 
cent.), 20 cc. ; distilled water, to 200 cc, is the formula given. The chemist, for 
the sake of accuracy, will make it up in much stronger solution, and then dilute 
to this proportion. 



THE BLOOD: ALKALINITY 



545 



Each addition is well mixed and the presence of the oxyhemoglobin 
lines determined by the hand spectroscope. An artificial light at a 
constant distance is recommended. The addition of acid is continued 
until these two lines disappear. A direct reading of the number of 
milligrams of sodium hydrate may then be made. Dare gives a list of 
cases in which the alkalinity was decreased and of others in which it 
was increased. 

The apparatus we find ingenious and very constant in its results, 
and hope to gain some practical value from its use. 

Determination of Carbon Dioxide. — This method, which at first glance seems 
the most valuable, since one of the chief functions of the alkalinity is to bind the 
carbon dioxide, is both hard in technique and not at all perfect in theory. In dia- 
betic coma the amount of gas has been found diminished to from one-half to one- 
third the normal amount. It has also been diminished in fevers, cancer, and leu- 
kaemia. But variations in the gas are not necessarily the same as variations in 
alkalinity. 

Rigler's Method. — Rigler's method is simple, and has found several cham- 
pions. Into a weighed flask containing 10 cc. of absolute alcohol is poured a small 
amount (3 or 4 cc.) of blood and is again weighed. Thus can the amount be better 
determined than volumetrically. This is allowed to stand for about half an hour ; 
10 cc. of distilled water are then added and it again allowed to stand half an hour. 
It is then titrated with fiftieth-normal H2SO4, using litmus as indicator. 

Brandenburg's Method. — The total alkalinity is first determined by a modified 
Lowy method, lacmoid as indicator. Three portions of defibrinated blood of at 
least 20 cc. each are placed in vessels for osmosis work, each separated by diffu- 
sion membranes from NaOH solutions in 0.8 per cent. NaCl, the one of which is 
one-fourth, the second one-fifth, the third one-sixth the alkalinity of the total 
blood. At the end of twenty-four hours the alkalinity of the fluid without the 
membrane, and of the blood-mixture within, are determined. Limits between which 
the diffusible alkalinity stands are thus determined. 

It will be seen that this has limited clinical value as a routine determination, 
but has taught much concerning our other methods and results. 

Salkowski's Method. — Salkowski's method is certainly simple. A known 
amount of ammonium sulphate is added to the blood and the ammonia of the salt 
thus set free determined by Schlosing's method. 

Under a bell-jar are placed 20 gms. of finely pulverized ammonium sulphate 
which have been dissolved in 20 cc. of water. In a receptacle above this are placed 
10 cc. of fourth-normal sulphuric acid. One then pours into the lower dish 10 cc. 
of blood. The measuring-glass to be used for the blood is first washed in 1 per 
cent, sodium oxalate solution to prevent coagulation. The blood is mixed with the 
ammonium sulphate solution, and the whole covered at once with the bell- jar. In 
five or six days all of the ammonia set free from the ammonium sulphate will have 
been taken up by the sulphuric acid and its amount determined by titrating this. 
By this method the alkalinity has been found for men, 350 to 400 mg. of NaOH 
per 100 cc. ; for women, 300 to 350 mg. 

In fever cases and anaemia cases it is diminished. 

The conclusions from these results are rather hard to state, che 
different methods giving quite different figures (Bezancon and 
Labbe) : 

Rumpf, Landois : 182 to 218 mg. NaOH per 100 cc. of blood. 
Lepine : 203 to 276 mg. NaOH per 100 cc. of blood. 
Bererd: 450 to 500 mg. NaOH per 100 cc. of blood. 



546 



CLINICAL DIAGNOSIS 



Tauszk: 700 to 800 mg. NaOH per 100 cc. of blood. 

Brandenburg: 300 total, 60 diffusible per 100 cc. of blood. 

Each method, however, has a certain empirical value. It has been 
found that the alkalinity in the case of men is greater than in women 
and is still greater in children. At birth high, it reaches a minimum in 
from one to three years, reaches the point normal for adult life at about 
sixteen, and slightly diminishes in old age. The daily variations in 
normal persons are slight. During digestion the alkalinity is slightly 
increased (due to the secretion of acid in the gastric juice). It is 
decreased by excessive exercise, supposed to be due to the formation of 
lactic acid. As a measure of the effect of various therapeutic pro- 
cedures no satisfactory results have been obtained, the effect of various 
alkalies or acids being very slight and transitory. The blood seems 
usually well able to resist any change in its reaction. 

The alkalinity of the total blood is always greater than that of the 
serum, since the corpuscles play no small part; the alkalinity rapidly 
diminishes until coagulation ; then is almost constant. Zunz found 
that in two minutes it fell from 330 to 170 mg. per 100 cc. The arterial 
blood is slightly more alkaline than the venous blood, but the difference 
is not great. 

Pathologically it is diminished in severe ansemia, especially the 
pernicious, but not in chlorosis ; in the high fevers, diphtheria, scarlet 
fever, and measles, increasing even to above normal during convales- 
cence; in uraemia, osteomalacia, and just before death. The most 
interesting cases are the acidosis due to cancer, malnutrition, profound 
cachexia, and above all else the coma of diabetes mellitus, in one of 
which cases the amount of acid per kilo was equivalent to 1.75 
grammes of HC1. 

The latest clinical method described is that of Moore and Wilson * who titrate 
serum obtained after coagulation of a small amount of blood in a glass capsule. 
By means of the Wright capillary pipette they make three determinations: (1) 
titrating the serum with varying dilutions of normal sulphuric acid, using a 1 per 
cent, solution of dimethylamidoazobenzol in alcohol as indicator; (2) titrating with 
sodium hydrate, using phenolphthalein as indicator; (3) incineration of serum or 
whole blood and titration of the ash as in the first method. 

Strouse t applied a slight modification of the first of these methods to the 
study of a large series of cases and found the results reliable. His studies, however, 
show that the changes in the neutralizable alkali are slight and not constant for any 
one disease, and, further, such changes do not bear any definite relation to the 
clinical picture. 

Already the ammonia of the urine has proved itself of practical 
value. We hope soon that the alkalinity of the blood upon which the 
reaction of the urine certainly depends will be as easily and accurately 
determined, for the clinical observations seem to indicate that it would 
be very valuable. As yet it is practically useless. 

* Bio-chemical Journal, 1906, p. 297. 

t Bull. Johns Hopkins Hospital, xix, No. 206, May, 1908, p. 137. 



THE BLOOD: ANJEMIA 



547 



Urea in the Blood. — A very simple method given by Herter 63 is 
as follows : A carefully measured quantity of blood is treated with 
three to four times its volume of absolute alcohol and allowed to stand 
twenty- four hours. The filtrate and washings are evaporated to dry- 
ness at moderate temperature, the residue taken up again in absolute 
alcohol, and again filtered. The filtrate and washings are again evap- 
orated to dryness, and the residue dissolved in a little water. The 
nitrogen of this solution is determined by the sodium hypobromite 
method, exactly as in the urine. Other nitrogenous extractives of the 
blood, as creatin and lecithin, will also furnish a little nitrogen, but 
these are small in amount and are not wholly broken up, while urea is 
by far the most abundant. This method is sufficiently accurate for 
clinical work. 

Anaemia. — Grawitz defines anaemia as a deterioration of the blood 
qualitatively and quantitatively as regards one or all of its constituents 
— the plasma, the corpuscles, and the haemoglobin. The term as gen- 
erally used means a reduction per cubic millimetre of the red blood- 
cells either in number or in volume. But these cells are really a rela- 
tively unimportant part of the total blood, having, so far as we know, 
but one function, and that a relatively minor although indispensable 
one, of carrying oxygen to the tissues, while the plasma contains the 
constituents upon which depend the life and health of the body, includ- 
ing the red corpuscles. In the plasma are the raw materials from 
which each cell gets new material for its structure, the food and fuel 
which it may use, and the many and as yet unknown bodies for its 
defence. 

By anaemia, properly speaking, we should mean a diminution in the 
total volume of undiluted blood. The proof of this is impossible. The 
reduction in volume does occur, as observations at the autopsy table 
show ; in cases of emaciation, for instance, and with a practically 
normal blood-count. On the other hand, by dilution with tissue-lymph 
the blood after a hemorrhage will maintain its volume, while the dilu- 
tion is manifested by the red blood-count. Lastly, in other cases, as of 
pernicious anaemia, there is evident diminution in volume of blood and 
of the corpuscles. 

But the essence of an anaemia is a poverty in the plasma of the 
protoplasm-building bodies, that is, of the proteids. Some have con- 
sidered that this was best determined by measuring the amount of 
water in the plasma, which may be supposed to increase as they de- 
crease, but this has proved unsatisfactory since a dilute plasma may 
mean only an increased volume, while in the severest anaemias (clin- 
ically) with low count the plasma can protect itself remarkably well, 
and chemically be almost normal. 

68 Jour, of Exp. Med., vol. iv. p. 119. 



548 



CLINICAL DIAGNOSIS 



From the practical point of view a diminution in the percentage of 
haemoglobin is accepted as the most sensitive index we have of any 
deterioration of the blood, and a diminished red blood-cell count a 
sign of a slightly more advanced grade, but first in value. 

By oligocythemia or hypocythccmia is meant a relative diminution 
in the number of red blood-cells ; that is, those of a unit volume of blood 
are absolutely diminished. This may be due either to an actuai reduction 
in number of the cells in the body, or to an increased amount of plasma. 
By oligochromccmia is meant a diminution in the amount of haemo- 
globin per unit volume of blood. By color-index is meant the per- 
centage of haemoglobin divided by the percentage of the red blood- 
cells, 5,000,000 cells considered as 100 per cent. (See page 500.) 

By oligccmia is meant a diminished amount of blood in the body. 
This may be suspected, but cannot be proved. Oligccmia serosa is an 
oligaemia of diluted blood; oligccmia sice::, an oligaemia with blood 
qualitatively normal. Hydrccmia means an increased percentage of 
water, and occurs whenever there is a diminished amount of albumin. 
Polyplasmia is an increase in the volume of the plasma, supposed to 
occur in chlorosis ; oligoplasma, a decrease, which occurs in certain 
cardiac diseases. By plethora vera, an increase in the total volume of 
blood. This can only be suspected. 

By the hematopoietic organs one usually means the organs forming red and 
white corpuscles ; the bone-marrow, spleen, and lymph-glands. The bone-marrow 
certainly is the building-place for red corpuscles and many leucocytes ; the spleen 
is active, perhaps, after a severe hemorrhage, but otherwise is probably unimpor- 
tant so far as the red blood-cells are concerned ; it is possibly important in the 
formation of leucocytes, and is quite probably the organ which removes the old 
cells ; the function of the lymph-glands as haematopoietic organs is still in doubt. 

The red blood-cells have, so far as we yet know, the one function of trans- 
porting the oxygen to the tissues, an indispensable but relatively minor function 
of the blood. The function of the leucocytes is still imperfectly known ; in general, 
they are said to be important in immunity, in the protection of the body against 
invading organisms, or toxins ; in nutrition, since by means of them a great deal 
of neutral fat is absorbed into the intestine ; and by going to pieces they certainly 
raise the albumen content of the blood. The function of the platelets apart from 
coagulation is not well known. While these functions of the formed elements are 
very important, those of the plasma of the blood are far more so, and we 
study the former because they are as yet the only index of the condition of the 
latter. Yet in studying the causes of anaemia those organs which form the plasma 
must be considered the most important haematopoietic organs. These are espe- 
cially the intestine, the liver, and the kidneys, although every organ modifies to 
some degree the composition of the plasma. It is in the intestinal wall that the 
plasma obtains its proteid content ; in the liver that the excess of carbohydrate is 
removed, or more furnished when necessary, that the 'ashes of the body are trans- 
formed to urea, etc. ; and it is in the kidneys that the most of the ashes are 
removed. Certain of the glands with internal secretions are also important in 
modifying the constitution of the blood. The pancreas furnishes the internal 
secretion necessary in sugar metabolism, while the importance of the thyroid and 
the adrenal is well known. Lastly, in the muscles themselves the blood is modified, 
since they remove certain food constituents and fuel, and give in return the ashes of 



THE BLOOD: SECONDARY AjSLEMIA 



549 



these bodies. It is thus seen that every organ of the body is a blood-building or 
blood-modifying organ, either adding to or subtracting from the plasma certain 
bodies, and that the blood will suffer from disease of any one of these organs but 
especially of the intestine, liver, and kidneys. In nearly all disease of the blood 
it is probably the plasma that suffers first, and in many of the anaemias the diminu- 
tion either in amount or in value of the red blood-cells may be merely the expression 
of changes produced in the blood-building organs by the abnormal plasma. 
The corpuscles cannot stay normal long in an hydraemic plasma. In pernicious 
anaemia and other toxaemias the element of blood destruction is of course also very 
important. 

The anaemias may be classified as primary and secondary. By 
primary is meant one for which an adequate cause cannot be assigned. 
Here are included chlorosis, the essential idiopathic anaemias, the sim- 
ple primary and the pernicious, leukaemia, and pseudoleukaemia. By 
secondary anaemia is meant one for which the cause assigned seems ad- 
equate to explain the blood condition. Under these causes are grouped 
hemorrhage, blood poisons, malnutrition, increased albumin destruc- 
tion, cachexia, and poor hygienic conditions. The above classification 
is purely clinical, not haematological, and the autopsy table not infre- 
quently shows to be secondary an anaemia which was during life sup- 
posed to be primary. The blood pictures are by no means sufficiently 
distinct. Points of differential diagnosis are easy enough to tabulate, 
but rather hard to apply in an individual case unless marked, and yet the 
anaemias of known cause seldom resemble the pernicious variety and 
it is seldom one finds a case with the picture of secondary anaemia and 
the cause not known. With the clinical history, the physical examina- 
tion, and the blood examination, the diagnosis is usually satisfactory, 
but not always. 

By hypoplastic anaemia is meant one due to insufficient blood forma- 
tion. By consumptive ancemia one due to increased blood destruction. 

From the haematological point of view one separates the c hi or otic 
and pernicious forms. These terms are used carelessly. By the former 
is meant a slight or no reduction in the number of red cells and a 
definite often considerable reduction of the haemoglobin. In this list 
are nearly all the milder grades of secondary anaemias, the primary 
chlorosis and the leukaemias. By " pernicious" in this connection is 
meant a great reduction in both cells and haemoglobin, equal or with 
the color-index higher than i. Such cases are the primary pernicious 
and rare cases of almost any extreme form of secondary anaemia. 

Secondary Anaemia. — A secondary anaemia is, from the point of 
view of the pathologist, one of which the cause, known or suspected, 
seems sufficient to explain the condition. But whatever the cause, the 
picture which the term brings to mind is that of a blood of which the 
haemoglobin is more reduced than the count of reds, and the plasma 
hydraemic. The red cells are usually smaller, of lighter weight, while 
some are large and " waterlogged." 



550 



CLINICAL DIAGNOSIS 



Cabot suggests a classification for the secondary anaemias which is 
useful. Mild cases are those with a normal count, but with the haemo- 
globin diminished ; specific gravity slightly lowered ; the count of the 
red blood-cells normal, yet a good many of them of light-weight, i.e., 
small and pale in appearance, are seen. A moderate grade is one with 
a normal count, but the reds show qualitative changes ; degenerations, 
microcytes, poikilocytes, crenated cells ; the cells stain abnormally ; 
there is less tendency to rouleaux formation. Severe cases are those 
with both qualitative and quantitative changes ; the count, however, is 
not much reduced except in the anaemias of childhood, after large 
hemorrhages, in malaria, and in acute septicaemia. Very severe cases 
are those with all of the above mentioned changes, and in addition 
evidences of degeneration and destruction of the cells ; evidence of 
regeneration (nucleated reds) will also be present. 

Blood Picture. — In secondary anaemia the blood may grossly be 
pale. The reds are less reduced than the haemoglobin, and their count 
may be normal. In severe cases, however, there will be a great reduc- 
tion ; in a*. Limbeck's for instance with recovery, 306,000. A reduc- 
tion of 1,000.000 cells, Bezancon and Labbe consider a mild hypocy- 
thaemia, one of from 2,000,000 to 3,000,000, an intense, while if the 
cells are reduced to one million, an extreme hypocythaemia. 

The reduction in Jiccnwglobin is the constant and most important 
feature, and the best index of the grade (yet see page 500). The color- 
index is lowest in cases due to cancer, hemorrhage, and gangrenous 
processes, yet in none of these cases is it quite so low as in chlorosis. 
On .the other hand in cases with extreme oligocythaemia the body, if 
given sufficient time, seems to protect itself by increasing the color- 
index, that is, by the production of cells which in size or weight are 
normal or above normal. Some think that the high color-index of 
pernicious anaemia is itself not characteristic of the disease, but an 
expression of the low count, the body, because of the chronicity of 
the disease, having had time to thus protect itself, while in those 
cases of secondary anaemia with low count and low color-index the 
acute course prevents this protective measure. The specific gravity 
of the blood is low. The dried residue is reduced. This is especially 
true in the cancer cases. (In one case of cancer of the stomach with a 
count of 1,400,000, 15 per cent. Hb, the dried residue was only 9 
per cent.) 

Morphologically, the stained cells show a lack of haemoglobin, and 
yet a good many are normal. In many the biconcavity is very evident, 
and pessary forms are common. The polychromatophilic degeneration 
is common, is seen within twenty-four hours after a hemorrhage, but 
bears no relation to the haemoglobin-content of the cell. The number 
of these basophilic cells runs fairly parallel to the grade of the anaemia, 



THE BLOOD: SECOND AEY ANJEMIA 



551 



so much so that this easy method has been suggested as a substitute for 
the more difficult of blood-counting (Walker). 

Poikilocytes occur only in the severest cases, unless the term be 
used to include the variations in size, for the cells are much reduced, 
although unevenly so. Microcytes always occur, some even 2 microns 
in diameter. Large cells with " acute dropsy" have been described. 

Nucleated reds vary much in number. This bears no relation to the 
anaemia, either its grade or its cause. They are abundant in some 
cases, as in acute post-hemorrhagic anaemia and in some chronic cases, 
while in others of the same degree they are absent. They may occur in 
crises (see page 513). The cells are normoblasts as a rule, microblasts 
occur in the severe post-hemorrhagic type, and megaloblasts are ex- 
ceedingly rare except in cases of malaria and other diseases which 
affect the bone-marrow. 

The leucocytes vary, depending on the cause of the anaemia and its 
complications, from a leucopenia to a leuksemic condition. Anaemia is 
a great stimulus to the bone-marrow, which during convalescence in- 
creases the count of the white blood-cells as well as of the red, hence, 
as a rule, there is a moderate leucocytosis with an increase in the poly- 
morphonuclear neutrophiles. In the other cases it is very hard to 
explain the picture. The eosinophiles vary much, from few to an ex- 
treme eosinophilia. As a rule they are at the upper limits of normal, 
and if further increased some other reason than the simple anaemia is 
the cause. 

The platelets are increased, even doubled in number. This is always 
true in the post-hemorrhagic cases. 

Acute Post-Hemorrhagic Anaemia This anaemia may be acute or 

chronic. The loss of one-half to two-thirds the volume of blood at one 
time is fatal. Women tolerate hemorrhage better than men, and chil- 
dren least well of all. 

The character of this anaemia depends upon the hemorrhage; 
whether the loss of blood occurred all at one time or at intervals. The 
clinical picture of these forms is very different. 

The blood immediately after a hemorrhage is normal qualitatively, 
then, as the tissue-lymph is poured in to restore the volume, the count 
and the haemoglobin diminish and the specific gravity becomes some- 
what less since the lymph is richer in water than is the plasma. The 
color-index should remain "1" for a short time, then decrease, since 
the new cells hastily formed are " light weight," smaller in size, paler 
in color, and more easily degenerated, both as regards their shape and 
staining qualities. It is possible, of course, that some of these degen- 
erated cells are old cells allowed to remain in the circulation longer 
than is normal, and that others are cells injured by the abnormal 
plasma. 



552 



CLINICAL DIAGNOSIS 



The loss of from 50 to 70 cc. of blood even will cause an appreciable 
increase in water. The count falls steadily until the dilution is com- 
plete, and then as the new cells appear the count slowly returns to 
normal, the haemoglobin somewhat later, it being weeks before the 
imperfect cells are entirely removed from the blood. The platelets are 
increased. The maximum hydremia after one hemorrhage and the 
minimum color-index are on about the ninth day. There is often a post- 
hemorrhagic leucocytosis. The regeneration of the red blood-cells is 
rapid at first, and then slower. This early rapid increase some think 
due to division of the red blood-cells of the circulation, and in favor of 
this is the number of the small cells and of poikilocytes which are so 
soon found. 

Nucleated reds may appear sometimes in large numbers, and dis- 
appear in about one week. They are chiefly normoblasts. Regenera- 
tion sometimes progresses in " steps" with blood crises (see page 513). 
The number of nucleated reds is often related more to the acuteness of 
the hemorrhage than to its severity. 

In one case 13.7 per cent, myelocytes were found, which disap- 
peared in three days. In another case of very severe post-hemorrhagic 
anaemia the polymorphonuclears were free from granules. 

An early feature in the regeneration is the production of many 
large cells, in some cases these being the chief element of the blood 
picture. 

Time for Regeneration after One Hemorrhage. — The table 
given by v. Limbeck is : 

Blood loss of 4.5 per cent, of body weight, thirty days to restore 
loss. 

Blood loss of 4 per cent, of body weight, twenty days to restore loss. 

Blood loss of 3 per cent, of body weight, ten days to restore loss. 

Blood loss of 2 per cent, of body weight, eight days to restore loss. 

But this varies with the age, nutritional condition, diet, and thera- 
peutic measures. Grawitz^says a loss of 3 to 4 per cent, of body weight 
requires fourteen to thirty days; of 1 to 3 per cent., five to fourteen 
days ; a slight loss, two to five days. 

Regeneration is quickest in men between twenty and forty years of 
age; slower in women, and slowest in children. After the regenera- 
tion is complete there may be even a hypercythaemia. Mikulicz stated 
that it was unwise to operate in cases in which the haemoglobin was 
already or probably would be 30 per cent, after the operation. In our 
cases, however, we have operated with the haemoglobin lower with 
good results. 

In animals regeneration may be almost entirely prevented by feeding an iron- 
poor diet, especially if by previous hemorrhages the iron reserve supply of the 
body has been exhausted — a very suggestive point in human pathology. 



THE BLOOD: SECO^DAKY ANAEMIA 



553 



In a case with repeated hemorrhages following abortion (pro- 
duced evidently by some drug, not by an operation) the count on ad- 
mission was 1,108,000; haemoglobin, 18 per cent.; leucocytes, 4625; 
temperature normal. 

In a case of hemorrhage from a badly crushed arm and after 
infusion the red cells fell in thirty-six hours from 5,000,000 to 3,000,- 
000, and the haemoglobin from 70 to 50 per cent. In a case of 
metrorrhagia the haemoglobin fell to 19 per cent., yet the patient 
recovered ; another with two post-partum hemorrhages had two weeks 
later only 1 1 per cent, haemoglobin, and yet recovered. 

Among the causes of this acute anaemia are traumatic hemorrhage, 
tubal pregnancy, in which a rapid anaemia is a bad sign, abortion 
(see above), uterine submucous tumors, ulcers of duodenum and 
stomach, typhoid ulcers, phthisis, aneurisms, varicose veins of oesoph- 
agus, rectum, or legs, the hemorrhagic diatheses, and hemorrhagic 
pancreatitis. 

A case of purpura hcEmorrhagica of eight weeks' duration 64 was admitted with 
a count of 696,000; haemoglobin, 17 per cent.; leucocytes, 4000 (small mono- 
nuclears, 75 per cent.). At death seven days later the red count was 483,000, no 
poikilocytosis (since too acute?), no nucleated reds, no eosinophiles. 

Ewing mentions a case of three weeks' duration with repeated epistaxis and 
a red count of 456,000. 

Anaemia from Chronic Hemorrhage. — The conditions which obtain 
here are very different from those following acute hemorrhage. By 
chronic hemorrhage is meant a succession of hemorrhages at such 
intervals that the patient cannot recover from the one before the next 
loss of blood occurs. If the intervals are long enough for complete 
regeneration the conditions are merely those of acute hemorrhage, and 
the amount of blood lost in the aggregate may be enormous, as was 
well seen in the former days when venesection was a common practice. 
Ehrlich mentions a Russian physician with pulmonary tuberculosis, 
who in six and a half months lost twenty kilos of blood — that is, four 
times the total amount, — and yet recovery was perfect. In case the 
intervals are shorter, even though the total amount of blood lost be 
relatively small, the results are more serious. A case with repeated 
epistaxis due to telangiectasis of the nasal mucosa was admitted here 
several times, once with red cells, 2,288,000; haemoglobin, 18 per cent. ; 
leucocytes, 2800. Scurvy, especially if with much hemorrhage, causes 
a secondary anaemia, the red count averaging from 3,000,000 to 
4,000,000. In one severe case it was reported as low as 370,000. A 
leucocytosis is often present but is clue to some complication, otherwise 
there is a leucopenia. In one case in this clinic the red cells were 
2,200,000 ; haemoglobin, 40 per cent. ; leucocytes, 2850. Other cases 



Billings, Johns Hopkins Hosp. Bull., May, 1894. 



554 



CLINICAL DIAGNOSIS 



follow hemorrhage from lungs, uterus, hemorrhoids, from intestinal 
ulcers, cancer of the stomach, intestinal parasites, cancers, etc. The 
severe anaemia from high and hidden piles is now attracting much 
attention. 65 After long anaemia the blood-building organs seem to 
lose their ability to regenerate the blood, and the picture becomes that 
of a primary anaemia, rapidly fatal and without any sign of regenera- 
tion. It is perhaps the poor nutrition of the blood-building organs 
resulting from the anaemia which results in the pathological direction 
of their activity or their entire loss of function. In other cases it is 
merely the result of the chronic disease causing the hemorrhage. It, 
therefore, takes much longer for the blood to regenerate ; in one case 
of hemorrhoids with a count of 2,600,000 it required eight months 
to reach normal (Ehrlich). 

In this form of anaemia the hydraemia is considerable, the specific 
gravity is low, and the dried residue considerably diminished. The 
red count is much diminished, even to* 1 ,000,000 cells. The new reds 
are small and pale, and the index low, 0.5 or even 0.44. The nucle- 
ated reds are scanty, the platelets increased. Sometimes, but seldom, 
the picture is that of a pernicious anaemia. While it may be that the 
patients die before this blood picture can develop, yet the evidence is 
against this idea since the index usually falls progressively lower until 
death. The leucocytes are increased at first, but when the anaemia 
becomes very severe there is usually a leucopenia. It seems as if 
the loss of blood protein was the element upon which all other features 
depend. 

Blood Poisons. — These may cause anaemia by shortening the life- 
period of the individual corpuscles. But since there is normally a 
good recuperative power, the poison must be severe, or if slight con- 
tinue for a long time, to have a marked result. Such poisons are 
produced in many infectious diseases, especially the septicaemias, scarlet 
fever and lues; chronic poisons, as lead, arsenic, and mercury; the 
toxines of intestinal parasites, as Bothriocephalus latus ; the poison 
arising in the intestine as the result of decomposition of the intestinal 
contents and in constipation ; and especially the toxine of malignant 
tumors. All these may cause anaemia. 

The effect of these poisons is sometimes seen in the red blood-cells in the 
circulation; the various degenerations, and the hsemoglobinaemia (plasmolysis). 
Other toxines are thought not to injure the cells in the circulation, but to cause an 
increased activity on the part of the blood-destroying organs, the liver, the spleen, 
and the marrow, without any haemoglobinsemia. One of the best illustrations of 
the effects of such a supposed toxine is hsematochromatosis, with the deposition of 
so much iron-containing pigment. The probability is that there has been a chemical 
(plasmotropic) change in the protoplasm of the cells which singles them out thus 
for destruction. Some poisons are thought to be purely plasmotropic, as for 
instance, lead, the toxine of cancer, of certain bacteria, and of ptomaines. Others 

65 See Herrick, Jour. Am. Med. Assoc., September, 1902. 



THE BLOOD: SECONDABY ANAEMIA 



555 



in small doses are plasmotropic, in larger doses plasmolytic ; in other cases the 
anaemia is thought to depend on the great differences in resistance of the reds 
(Gravvitz). 

Anaemia of Inanition; the Anaemia of the Poor. — This form is con- 
sidered by some as a simple primary anaemia, by others as a secondary 
anaemia but due to a variety of concurring factors the relative impor- 
tance of which cannot be apportioned, such as poor food, lack of sun- 
light, bad air, worry, and overwork. 

Starvation alone will not cause anaemia; that is, not qualitative 
changes in the blood, but animal experiments as well as clinical obser- 
vations have shown that there is a true anaemia, that is a diminution 
in the total volume of blood which runs parallel to the loss of weight. 
The blood picture of anaemia begins with the regeneration, since with 
the improvement in condition the blood does not keep pace with the 
gain of the other organs, and hence is diluted. The blood of Cetti, who 
fasted ten days, showed a rise in the red blood-cells of one million, a 
slight fall in the haemoglobin, while the leucocytes fell from 12,000 to 
4200. Others (Grawitz) consider that in some cases there is not 
simple atrophy of the total blood, but a loss of albumin of the plasma, 
hence a true anaemia. This is more evident if the days of fasting are 
alternated with days of slight nourishment, since the partial restoration 
of volume graphically becomes apparent. This is well seen in typhoid 
fever during the fourth week, in which case there is a rapid fall in the 
blood-count. 

Poor food is an important cause of chronic anaemia of the purely 
hypoplastic form (Immermann). This anaemia is of the purest type, 
since it is due to insufficiency of blood formation. It is not so much 
the quantity as the quality of the food which is of importance, and 
unfortunately for the poor the most important foods, those containing 
iron, are the most expensive. These cases are met with particularly in 
those European countries where the diet of the poor consists of bread, 
potatoes, and other cheap food of similar nature. In this country, 
where there is by no means such a large class of poor on such miserable 
diet, the trouble is not so much the quality of the food as its prepara- 
tion, good meat and vegetables being rendered indigestible by prepara- 
tion in the frying-pan. In addition to this must be included the hurry 
in eating and the insufficient mastication of the food, which is a com- 
mon sin in all grades of society. Bunge's experiments have shown 
that a diet poor in iron causes anaemia in a growing child, and yet it 
cannot be the lack of iron alone, since even the poorest foods have 
sufficient of this metal to replace the actual loss on the part of the 
body. With a truly non-proteid diet the effect on the blood can be 
demonstrated at the end of six or eight days, the first effect being a 
slight hydraemia, later the changes in the red blood-cells, which are 
probably secondary to the former. 



55G 



CLINICAL DIAGNOSIS 



Those living in dark houses are very apt to be anaemic. This is not 
due alone to the lack of sunlight, since haemoglobin is not exactly 
comparable to chlorophyll, as the illustrations given by Ehrlich show ; 
the horses which for from ten to twenty-four years are kept at the 
bottom of mines in Germany without seeing sunlight have normal 
blood; the members of Nansen's Polar Expedition remained for one 
hundred and forty to one hundred and fifty days without sunlight, and 
yet were healthy since the other causes of anaemia were eliminated. 
Although sunlight may not be so important for the adult, yet it has 
been shown to be important for the growing organism (Schonen- 
berger). 

To live constantly in an atmosphere of bad air also seems to pre- 
dispose one to anaemia and an excess of carbon dioxide is cited as the 
real cause, and yet the real relation of this single factor to anaemia it is 
difficult to determine. 

In review it may be said that these factors all combine to cause the 
anaemia of the poor, and yet of them all overwork and worry, with 
their serious influence upon digestion and the nervous system, are 
probably the most important ; hence it is that " anaemia of the poor" is 
really a misnomer, for the rich also suffer from disturbances of the 
gastro-intestinal tract which render their food almost as little nour- 
ishing, and worry is perhaps more their lot than that of the poor; 
hence it is that anaemia is perhaps quite as common among them. 

There is a group of cases we diagnosed as secondary anaemia for which no one 
cause can be assigned. The great majority were women; the red cells showed a 
mean of about 3,000,000 (2,100,000 to 3,900,000) ; haemoglobin, 30 to 50 per cent; 
leucocytes, about normal. Such cases improve rapidly in the ward. 

As has been said, one of the most important haematopoietic organs 
is the intestinal wall, the source of supplies for the plasma, hence indi- 
rectly for the cells. 

Gastro-intestinal disturbances are some of the most impor- 
tant causes of secondary anaemia, and perhaps of many cases in which 
the intestinal feature is overlooked. 

In our cases of severe diarrhoea in men, in 60 per cent, the red count 
was not above 4,000,000; in women the counts ran higher. The real 
anaemia must have been more pronounced than this, for in some cases 
the blood was probably concentrated by the loss of fluid (one case with 
7,900,000). 

The leucocytes ran low (even to 2700 and 2500) in some cases, but 
above 10,000 in 30 per cent, of all. 

Cabot mentions a case with 1,928,000 reds, another with 2,440,000 
and 10 per cent, haemoglobin. 

In chronic dysentery the count is high or low. One case had 



THE BLOOD: SECOKDABY ANEMIA 557 

1,520,000 red cells, another 2,500,000. On the other hand, one (male) 
had 7,000,000 reds, 110 per cent, haemoglobin, and 7000 leucocytes, 
and one (a woman) 6,300,000 reds. 

In chronic constipation our cases showed normal or high counts, as 
w r ould be expected. 

Our cases of dilated stomach showed nothing abnormal as regards 
the leucocytes ; for the most part the red count fell within normal 
limits, but four showed considerable anaemia (3,300,000, 2,400,000, 
2,250,000 and 2,600,000). Those cases with the vomiting of large 
amounts of fluid should have a concentrated blood ; all severe cases 
would be expected to show some anaemia of malnutrition. 

Acute gastritis during the febrile period shows a slight leucocytosis, 
true of 70 per cent, of our cases of gastro-enteritis. A slight leucocy- 
tosis is also common in chronic gastritis, except the alcoholic form in 
which cases the counts may be quite low. 

One case of chronic dyspepsia had a count of red cells, 1,960,000; 
haemoglobin, 42 per cent, (index 1.1); leucocytes, 3600 (of which 
s. monos., 1 1.3 per cent. ; 1. monos, and tr., 0.3 per cent. ; pmn. n., 85.6 
per cent. ; eos., 2.6; normoblasts, 2 per 100 leucocytes). 

In ulcerative colitis counts below 3,000,000 are not rare. 

In amoebic dysentery one would expect the count to be little af- 
fected since the intestinal lesion is so local, and severe anaemia is rare, 
yet in 24 per cent, there was a slight (4,000,000 to 4,500,000), and in 
12 per cent, a more severe (2,200,000 to 4,000,000) anaemia. A leu- 
cocytosis was the rule (70 per cent, of cases) at some time during the 
disease, the highest count being 19,200. Futcher 66 found the general 
average of forty-three cases about 10,000. In children Amberg found 
an eosinophilia. 

Anaemia of the Tropics. — It is said that Europeans after a stay of some time 
in the Tropics seem anaemic. Some consider this only apparent, and due to the 
distribution of the blood. The presence of basophile granulations in the red blood- 
cells, seen soon after the arrival there, and which were first described as related 
to malaria, would seem to indicate an injury to these cells. There are several 
tropical diseases, important causes of anaemia, which only now are we beginning 
to understand. These may explain some of the above cases. 

Chronic Infectious Diseases. — Of these there are three which are 
most potent causes of anaemia, — lues, tuberculosis, and leprosy. While 
the toxine of the disease may be the most important element, yet the 
nutritional condition, especially the condition of the gastro-intestinal 
canal, the lack of exercise, and hemorrhages must also be included. 

There is a great difference in toxines ; in acute miliary tuberculosis 
without cyanosis, one of the worst septicaemias, there is little trace 
of blood destruction (see page 598). 

66 Jour. Am. Med. Assoc., August 22, 1903. 



558 



CLINICAL DIAGNOSIS 



Anaemia is a common result of pus formation, and is due both to 
the toxines from the pyogenic organisms and to absorption from the 
pus focus of breaking-down tissue, and probably also to the over-taxa- 
tion of the blood-building organs. The same is true in diseases with 
chronic exudate formation. Albuminuria is frequently cited as the 
cause of anaemia, and yet the actual daily loss of proteid to the blood- 
plasma even in a severe case is very slight, and could easily be replaced 
by one good meal. The poor condition of the digestive canal of ne- 
phritics is also important, but surely there is some toxine which has a 
deleterious effect upon the blood, as well as it surely does on the rest 
of the body functions. Dieballa has found a definite relation between 
the albuminuria and the hydraemia. 

Spermatorrhoea, lactorrhcca, and diseases of the respiratory organs 
with a large amount of sputum are further causes. Yet cases with 
chronic purulent exudate formation maintain their blood condition sur- 
prisingly well, considering the drain there is on the blood, as in cases 
of chronic bronchitis and tuberculous abscess (see page 598). In all 
such cases it is the plasma which suffers first, the red blood-cells second. 

In cases with marasmus there is an atrophy of the total blood which 
may cover an anaemia, while in other cases the anaemia may be more 
apparent than real, since there is a dilution of the plasma. At this point 
also may be mentioned the dilution of the blood from the absorption of 
effusions or other retained fluids. On the whole, the regulation of the 
blood is simply wonderful; for instance, after the removal of even 
seven litres of ascitic fluid at one time and its rapid reaccumulation the 
blood will show very little evidence of this enormous flux of fluid 
through the blood-vessels. 

Fever is stated to be an important cause of anaemia, and yet it 
is not the elevated temperature but the toxines which cause the rise 
which also destroy the red cells, as evidenced by the increased hydro- 
bilinuria. Most important are those cases of chronic cryptic septi- 
caemia which for weeks may present the picture of severe anaemia 
without any suspicion as to the true nature of the trouble. On the 
other hand, acute infections will cause a rapid fall in the blood-count, 
as for instance Grawitz's case of streptococcus septicaemia, in which in 
a little over one clay the reds fell from normal to 300,000. 

A recent case of arthritis of unknown cause, but with blood-cultures 
negative, had a count which fell to, red cells 976,000 ; haemoglobin, 1 7 
per cent. ; leucocytes, 4600. He improved rapidly. 

In yellow fever considerable anaemia is found, in one case the count 
being 2,604,000, in another 1,400,500 (Maurel). 

Pneumonia, diphtheria, scarlet fever, typhoid, acute articular rheu- 
matism, smallpox, septicaemia, and other acute infectious diseases may 
cause a severe anaemia. The reader is referred to the various sections 



THE BLOOD: SECONDAKY AN.EMIA 



550 



on these diseases. In all cases, for the first few days at least, there may 
be no diminution in the red blood-count, even a hypercythaemia due to 
the concentration of the blood, seen best in diphtheria and typhoid 
fever, and which may cover a real anaemia. The rapid fall in the count 
which comes during convalescence or at the time of the crisis, as in 
pneumonia, is probably more apparent than real, and due to dilution of 
the blood resulting from the general vasomotor relaxation at that time 
(Grawitz) ; but the toxine of the infecting organisms may also be 
important by causing haemolysis. 

In many cases there is a drop in the count, but the quantitative 
changes are remarkably slight ; only in very severe cases are micro- 
cytes, macrocytes or poikilocytes present. Hydraemia is the rule, the 
loss of albumin running parallel to the severity of the disease, and in 
severe cases reaching even 6.25 gms. of residue to 100 cc. of blood. 

Intestinal Parasites. — Of these there are two famous as causes of 
anaemia. 

Uncinaria Duodenalis et Americana. — Historically this form 
of anaemia is most interesting, since the cases of miners' and tunnel 
diggers' anaemia due to this parasite were first rated as primary per- 
nicious anaemia, at a time before the distinctive blood-features of the 
primary and secondary anaemias were understood; now it is claimed 
the picture can rarely simulate the pernicious type. This parasite 
occurs in many different countries and bids fair to prove to have 
been one of the most important causes of anaemia; it is now thought 
to be in this country the chief cause of the " anaemia of the South." Our 
one marked case during the past five years had a count of red cells of 
2,424,000 ; haemoglobin, 32 per cent. ; leucocytes, 9700 ; eosinophiles, 
5.6 per cent.; but in some epidemics the count falls below 1,000,000 
cells. 

The cause of the anaemia is disputed. That it resembles one due to haemor- 
rhage rather than to a toxine is seen from the small amount of iron in the liver, it 
being diminished even to one-quarter its normal amount, to the absence of a leuco- 
cytosis, and the very low color-index. 

In our three cases of strongyloides intestinalis infection the 
blood showed : red cells 5,420,000, haemogobin, 82 per cent., leucocytes, 
6200; 3,560,00, 57 per cent., 21,500; and haemoglobin, 60 per cent., 
leucocytes, 7500, respectively. 

Bothriocephalus Latus. — This parasite is the cause of a most 
interesting anaemia. It is a tape-worm which may live for years in the 
intestine of a person whose blood is normal, and yet in other cases 
cause the most severe anaemia, the almost exact picture, both quantita- 
tively and qualitatively, of the primary pernicious type, but which 
recovers after the worm has been expelled. In Lichtheim's case the 
red blood-corpuscles were 500,000 ; haemoglobin, 20 per cent. ; six 



560 



CLIXICAL DIAGNOSIS 



worms were expelled. In Schapiro's case the count was 837,000. and 
in twenty-three days after the worm was expelled, 2,975.000. Be- 
zancon and Labbe give as the average of reds 1.300.000. and the limits 
from 395,000 to 2,150.000; those of the color-index 0.9 and 1.62. 
All the degenerations and other signs of a severe primary anaemia, 
poikilocytes. microcytes, macrocytes, the polychromatophilic degenera- 
tion, etc., are present. Even one-half the nucleated reds are megalo- 
blasts. and yet in two weeks after the worm has been expelled the 
megaloblasts all disappear, and in three weeks the megalocytic blood 
returns to normal type, with even normoblasts gone. The leucocytes 
are normal both quantitatively and qualitatively. They vary from 
3000 to 12.000 (Schaumann). 

The reason for this anaemia is unknown, and 3-et when it does occur it is 
probably due to a toxine. It is not a loss of blood ; it is not the presence of the 
worm alone, since but 16 per cent, of the hosts of this worm are anaemic. Askanazy 
says it is the time that the worm is in the intestine, but even this does not hold, 
and some cases are hosts twenty years before the anaemia begins. Schaumann empha- 
sizes the predisposition of the patient. Dehio says it is the condition of the worms, 
only those worms which are diseased or dead causing the trouble ; but the diseases 
of the worm are not always evident, and there are cases with a manifestly degen- 
erated worm but no anaemia. Again, in other cases after the worm is expelled the 
anaemia is not cured : perhaps the ability for recovery has been lost. In this 
anaemia the iron of the liver has been found even twice normal in amount, which 
would indicate an intravascular destruction of the red blood-cells. The color- 
index is above normal. 

Other intestinal parasites. Taenia saginata and solemn, Strongy- 
loides intestinalis. in which counts as low as 760.000 have been reported 
(diarrhoea of Cochin China), Ascaris lumbricoides. are claimed, as 
occasional causes of anaemia, but the connection is as yet unsatis- 
factory. 

Poisons. — Lead, mercury, arsenic, certain organic poisons, plant 
and animal toxines. ptomaines, and the toxines of burns, all may cause 
anaemia. Lead is an especially potent cause, both of the acute and 
chronic forms. While it is essentially a chlorotic anaemia, manifested 
first by the degenerations of the red blood-cells, their count being prac- 
tically normal, it may be so severe that the count is reduced to even 
1.300,000. Malassez says that there is a slight increase of diameter in 
the reds, their rigidity is increased, and that megaloblasts sometimes 
occur. The basophile granules are very common and important ( see 
page 481). Whether the action of lead is directly upon the cells or 
upon the plasma first is uncertain, while some think this anaemia due to 
gastro-intestinal disturbances. 

We have had during the past few years 17 cases. In 16 cases the lowest was 
2.900.000 ; in 7 cases the red count was over 4,500.000 : the mean. 4.200.000. Haemo- 
globin, lowest. 38 per cent. ; mean. 60 per cent. In 10 of 16 cases the leucocytes 
were above 10.000. maximum 25,000, but fell very soon after admission. 



THE BLOOD: PERNICIOUS ANEMIA 



501 



Long-continued use of certain of the coal-tar products causes a 
severe anaemia. Stengel and White 07 report a most interesting case, 
a woman with reds 2,092,000; haemoglobin, 35 per cent.; leucocytes, 
19,800 (a previous count), and 2> 2 ,2> 2 2> nucleated reds per cubic milli- 
metre, of which 91.4 per cent were normoblasts, 3.5 per cent, megalo- 
blasts and 5.3 per cent, free nuclei. The platelets were increased. There 
were many poikilocytes, a few basophile granules, and considerable 
polychromatophilic degeneration. It is interesting that the diagnosis 
of this poisoning was made from the appearance of the smear alone, 
despite the repeated assertions of the woman of the impossibility. It 
was found to follow the use of acetanilide. They mention Ehrlich 
and Lindenthars case with nucleated reds in the proportion of 1 : 56 
of the red cells. In Brown's case of acetanilide poisoning 68 at death 
the reds were 1,166,000, and the nucleated reds 22,150 per cu. m.m. 

Splenic Anaemia is the name given to a group of cases with anaemia 
and idiopathic enlargement of the spleen. The anaemia is of the sec- 
ondary type, the average of Osier's cases being over 3,000,000 ; there 
is no leucocytosis, or a reduced count. Such cases have profuse hemor- 
rhage from the stomach and oesophageal varices. In one case in Osier's 
series the macrocytes and gigantoblasts were a marked feature of the 
case. 69 

Simple Primary Anaemia. — This form, which some separate from 
primary pernicious anaemia because of the differences in the clinical 
course, is also hard to separate from those secondary anaemias already 
mentioned as due to unhygienic conditions, poor food, hard work, 
worry, etc. It is a severe primary anaemia, characterized by the 
number of relapses, ending finally, however, in death. This type can 
be recognized only when the case is typical. It seems to stand midway 
between chlorosis and primary pernicious anaemia, some cases differing 
from the former only in the age of the patient, others presenting 
many features of the latter, and between them every gradation. Mid- 
way between these extremes is a group of cases with oligocythaemia 
and oligochromaemia of about equal grade, and leucocytes normal both 
quantitatively and qualitatively. 

Progressive Pernicious Anaemia. — Eichorst's definition of this was 
a severe anaemia which in spite of all treatment progresses relentlessly 
to death. Pathologically, there is no lesion of etiology. The blood 
picture alone is not characteristic, for several varieties of secondary 
anaemia may assume a somewhat similar picture — " secondary perni- 
cious anaemia." And yet the blood picture is so striking that the word 
" primary pernicious" now carries with it an idea of the blood picture 

6T Contrib. of the Wm. Pepper Laboratory of Clinical Medicine, 1903, No. 4- 

6S Amer. Jour. Med. Sci., 1901, vol. cxxi. 

69 Osier, Am. Jour. Med. Sci., January, 1900. 

36 



562 



CLINICAL DIAGNOSIS 



as well as its clinical and pathological significance. As illustrations 
of secondary pernicious anaemia are certain cases of cancer, phthisis, 
lues, malaria, repeated hemorrhage, lead poisoning, certain parasites, 
lesions of the bone-marrow, especially tumors, also osteomyelitis, 
atrophy of the gastric mucosa, stenosis of the pylorus, nephritis, cer- 
tain rare cases of pregnancy, and purpura hemorrhagica. In all the 
above cases there is a long history of anaemia-producing agencies, and 
this picture may represent the final stage, an almost complete bank- 
ruptcy of the blood-building functions. 

The salient characteristics of the blood of primary pernicious 
anaemia are: Signs of rapid blood destruction (the degenerated reds, 
endoglobular degenerations, polychromatophilia, the urobilinuria, 
jaundice, the increased iron compounds (?) in the serum and the cor- 
puscles, and the increase of iron stored in the liver and spleen) ; the 
poikilocytosis, a high color-index, and the megaloblastic blood forma- 
tion. At first the poikilocytosis was supposed to be characteristic 
(Quincke) ; this idea was very soon corrected. Then the high color- 
index (Laache and Kahler) was supposed to be the important feature, 
and this is now the opinion of many. A high-color index may occur 
in severe cases of secondary anaemias, but it occurs in mild primary 
cases. Ehrlich considered that megaloblasts were characteristic, but 
this also is not strictly true, although they are numerous here. 

Volume of the Blood. — Clinically there is no way of determining 
the volume of the blood, yet from the appearance of the patient we are 
often sure it is diminished, and at the autopsy table are sometimes 
astonished at the small amount of blood in the heart and blood-vessels. 
A remarkable case was seen by the writer in Professor Miiller's clinic, 
in which all the organs seemed almost exsanguine. 

Gross Appearances. — The ear is a better place to obtain the drop of 
blood than is the finger. It may flow freely, or it may be difficult to 
get any. Lazarus considers that the former occurs when the patient 
is doing badly, and that the latter is evidence of improvement. 

The blood is pale, of a light red watery color (Fleischwasser) , and 
does not at all resemble blood. 

We showed a tube full of this blood to a class on one occasion, asking them 
to tell from its appearance alone what fluid it was, and many of them said it was 
a cloudy urine, which, indeed, it did resemble. 

The drop of blood is often streaked, evidence that the corpuscles 
have collected in masses. Cases have been described in which it is 
grossly of a coffee-color, probably due to haemoglobinaemia. The 
coagulation time is often increased. 

Red Blood-Cells. — In the fresh specimen these are seen to be few in 
number, and there is absence of rouleaux formation. The cells vary 



THE BLOOD: PERNICIOUS AN.EMIA 



563 



much in size : many are slightly above normal, some very large ; many 
are small, some very small. Only a few of the cells show Maragliano's 
endoglobular degeneration, but many do show another degeneration, 
the accumulation of the haemoglobin in the centre of the cell. The 
most are of a uniform dark color. Nucleated reds will often be found 
in the fresh specimen. In a well-marked case the appearance of the 
fresh specimen alone will strongly suggest this disease. One has 
only to compare it with a specimen of normal blood, and the difference 
is striking. 

Count. — An extreme oligocythemia is the rule, and it is remark- 
able how few symptoms accompany these low counts, particularly as 
the volume of blood is also diminished. On the first visit the average 
cases will show a count of about 1,000,000 cells. Cabot's average was 
1,200,000. 

In our cases in the 102 admissions (several of the 81 cases being admitted more 
than once) the average first blood-count was 1,575,000. This is somewhat higher 
than that which other observers have reported, and is due to the fact that we had 
several cases admitted not for the symptoms of pernicious anaemia alone, but from 
attendant conditions, for instance, for nervous disorders. In 81 per cent, of our 
cases the count on admission was under 2,000,000 and in 12 per cent, under 1.000,000. 

A man with a count as low as 500,000 may remain comfortable 
and active, while others with four times that number of cells suffer. 
Evidently the reason for the symptoms is not the oligocythemia alone. 
Cabot thinks that the counts tend to remain at about 1,000,000 cells, 
dropping rapidly to this point and remaining there, then sometimes in 
improvement gaining rapidly to about 3,000,000; later to return to 
about this same figure. The count may remain stationary for some 
time, or it may diminish progressively until death. Quincke reported 
one case with a blood-count of 143,000, and yet who recovered. 
Hay em reported a fatal case whose lowest count was 292,000. Scott's 
case had at death 268,000 reds ; index, 2 ; leucocytes, 5900. 70 

After admission the count may continue to drop for a while, then 
to rise, or it rises at once, or it remains stationary. 

It cannot be too often emphasized that a change in count may mean 
a change in the total number of red cells or a change in the volume of 
plasma. 

An interesting fact already noted is that clinical symptoms seem to bear no 
relation to the red blood-cell count. Certain cases enter the hospital with a few 
symptoms and a blood-count of 1,500,000, while other cases are apparently in no 
worse condition and yet have a count below 1,000,000. The comparative comfort and 
physical strength of such patients is in marked contrast to cases of chlorosis and the 
secondary ansemias, which cases enter the hospital with the blood in an apparently 
much better condition. Again, in some of those cases in which the blood continues 

70 Am. Jour. Med. Sci., 1903, vol. cxxv. p. 397. 



504 



CLINICAL DIAGNOSIS 



to fall after admission and then to rise, it is curious that the patient feels so weli 
that he insists upon going home at a time when the count is no higher or very 
little higher than on his admission. In other cases in which the count rises after 
admission and then falls, death occurs when the count has reached the level of 
admission. In still other cases with an initial drop, as in five of our series, the count 
was rising at the time of death. 

Although patients come to the hospital for symptoms which bear little relation 
to their blood-count, yet the same case on two or more admissions will enter with 
counts which are curiously close. 

The red blood-count on the day of death in two of our cases was 
high — 2,700,000 and 2,100,000 ; in three cases moderate, 1,031,000, 
1,326,000, 1,216,000; and in thirteen cases, and this we think a hint 
of the blood picture at death due to this anaemia alone, the count was 
between 718,400 and 376,000, an average of 567,700. 

The blood during intermissions is not quite normal. The red count is about 
3,000,000, and the cells still large (Cabot). The color-index, however, is sometimes 
low, and the leucocytes increased by an increase in polymorphonuclears ; nucleated 
cells disappear. The diagnosis now is important, especially to insurance examiners. 
In a recent case with almost normal blood the diagnosis was made by one examiner 
and the case refused. He succeeded in getting heavy insurance in another company, 
and died in about one year of this disease. 

The volume of the red blood-cells is best determined by sedimenta- 
tion. The average volume, instead of the normal 45 to 50 per cent., is 
from 8 to 10 per cent., which seems high, considering the count, and is 
a measure of the large size of the cells. Capps found the volume index 
always above the color-index, hence the size of the cells explains satis- 
factorily the latter. 

Size. — The average diameter of the red cells is somewhat in- 
creased, with, however, wide variations, the cells measuring from 4 to 
13 microns, and with extremes beyond these. The average diameter 
may be 9 microns. In no other disease are there so many macrocytes. 
It is not the average but the mean size, or the percentage of macro- 
cytes, which is of importance in diagnosis, since the microcytes will 
lower the average. 

Macrocytes. — Seventy per cent, of the cells may be very large, 
between 11 and 13 microns in diameter (Lazarus). In a case reported 
by Ewing 90 per cent, measured from 11 to 16 microns. Gigantocytes 
also occur. These large cells are less biconcave than normal, some are 
not biconcave at all. Some are oval ; some seem flabby ; they are 
often dark colored in the fresh, often polychromatophilic in the stained 
specimens ; they never present the pessary form ; some, however, are 
pale, according to Grawitz many are, but the dark color of many of 
the large cells is, we consider, a quite constant feature, and one recog- 
nized by students when studying the fresh blood of patients concerning 
whom they know nothing. Students should be given many such 
specimens to study, always making a specimen from normal blood for 



THE BLOOD: PEKNICIOUS ANEMIA 



565 



comparison, until they will say unhesitatingly whether the size of the 
average cell is increased or not, and whether the color is darker or 
lighter than normal. The differences are more striking than would 
be expected by one not trained to observe them. In some cells there 
is a slight change of color shade as well as of depth. There are cases 
in which the blood is said not to be megalocytic. Macrocytes are 
not common in normal bone-marrow, and their presence here is con- 
sidered (Laache) a compensatory attempt to replace the amount of 
haemoglobin-containing protoplasm. Cohnheim first said it was rever- 
sion to the embryonic type. Ehrlich attributes it to a megaloblastic 
degeneration of the bone-marrow. 

Microcytes. — These cells vary from 2 to 6 microns in diameter, 
and are usually of a deep color. They occur in large numbers also in 
secondary anaemias. They may fail here. So numerous are these cells 
in some cases that the average size of the red blood-cells is not above 
normal ; hence the importance of judging the mean rather than the 
average size. The dark color of these microcytes may be due to their 
spherical shape, but they have sometimes a greenish tint, which would 
indicate a chemical change in the protoplasm. These microcytes might 
be suspected to possess amoeboid motion, at least they change their 
shape and move quite actively among the other cells with an oscillatory 
motion. They have been described as monads, a leptothrix form, bac- 
teria, and Hayem called them pseudo-parasites. It is very interesting 
to watch them in their movements. Such cells are pictured in Fig. 93. 

Poikilocytes, the presence of which was supposed formerly to be 
a characteristic feature of the blood in primary anaemia, occur often 
in large numbers and in a great variety of shapes. Hook, raquette, 
spindle, and various dwarf forms occur. The sausage and the battle- 
dore shapes were formerly supposed to be found only here. The 
small forms show interesting contraction phenomena resembling 
amoeboid motion (see above). 

It is not unusual to find shadows among the deep-colored red cells. 
Since in a rather acute case abnormal cells did not appear until about 
two months from onset, McCrae suggests that such cells occur only 
after the condition has existed for some time. 

Polychromatophilic Degeneration. — This is best studied in 
pernicious anaemia. Although it is not always a sign of degeneration, 
in this disease for the most part it seems to be. With Ehrliclrs triple 
stain these cells are a pale gray (Plate I, 25-28). With methylene 
blue they take a blue tint. Their number is almost parallel to the 
severity of the case (Grawitz). Red cells with Grawitz's basophile 
granules are very common, especially in severe cases, and have, 
Grawitz thinks, an important prognostic value. 

Nucleated Reds. Normoblasts (Plate I, 29, 30, 35, and Fig. 113, 



566 



CLINICAL DIAGNOSIS 



a, c, d,e). — These cells, described on page 512, occur quite constantly in 
pernicious anaemia, alone or with megaloblasts, and in especially large 
numbers during the blood crises. In a case of Bezancon and Labbe 
there were from 6000 to 10,000 normoblasts and 960 megaloblasts per 
cubic millimetre. Many of these cells show polychromatophilic degen- 
eration, especially those in which the nucleus is dividing. 

The blood crisis, so interesting a feature in cases of severe anaemia 
(see pages 513 and 568), is not always, as v. Xoorden thought, the 
sign of a regeneration active enough to be followed by a jump in the 
red count, although in secondary anaemia and chlorosis this may be the 
case. The crises probably do indicate an attempt of the bone-marrow 
to replenish the blood, but in some cases of pernicious anaemia they 
are followed by a fall in the red count, the convulsive attempt to stem 
the tide of destruction proving futile. Those followed by improvement 
occur especially in younger persons. 

In some cases there are few or no nucleated reds in the peripheral 
blood. This means a slower regeneration. In other cases just before 
death all' these cells disappear. 

Megaloblasts (Plate I, 32, 33, 38, and Fig. 113, f). — These cells 
were first described by Ehrlich as characteristic of pernicious anaemia. 
Thev may, however, occur in any anaemia, and in anv disease involving 
the bone-marrow. The difficulty in forming- a judgment concerning 
their occurrence lies in the fact that cells which one man counts as meg- 
aloblasts others do not. Many criteria have been proposed for their 
recognition — the size of the cell, the size of the nucleus, the structure 
of the nucleus, etc. Since the presence of these cells is so important 
in diagnosis it is safer when in doubt about a cell not to call it a 
megaloblast. One sees larg-e cells with nuclei like those of normoblasts 
and small cells with nuclei like those of megaloblasts. Both of these 
groups we count as intermediate cells, and reserve the term megaloblast 
for a large cell whose nucleus is about the size of a normal red blood- 
cell ; that is, about 7 microns. These cells are round or oval ; they vary 
from about 11 to 20 microns in diameter. When very large they are 
called gig-antoblasts. They are plump, often diffluent, and polychro- 
matophilic. The nucleus in the fresh specimen has a well-defined 
chromatin net-work, but takes, with the Ehrlich stain a pale greenish 
tint, staining so faintly that it may be overlooked ; it is large, plump, 
round or oval, especially the latter; it is often surrounded by a clear 
circle, and outside of this circle the protoplasm often stains deepest; 
karyokinetic figures are sometimes, seen, to find which some consider a 
grave sign. It is no easy matter to tell a polychromatophilic megalo- 
blast with a palelv staining- nucleus from some mononuclear leucocytes, 
and, strange as it may seem, sometimes men of recognized authority 
differ whether to call a stained cell white or red (Plate I, 36). Color, 



THE BLOOD: PEENICIOUS AXJJIIA 



567 



in a stained specimen, counts but little ; the opacity of the protoplasm 
counts much, the red cell being more opaque. The point upon which 
most depends is the edge of the cell, for the spherical leucocytes must 
flatten out in the preparation, and so have a thin frayed margin, while 
red blood-cells, being disks, do not flatten, and have a thick, smooth, 
uniform, rounded edge, best seen when one cell touches another. 
Again, the edge of a leucocyte may overlap a neighboring cell, but the 
edge of the red cell merely flattens against it. There is no staining 
reaction which is characteristic for haemoglobin, especially when baso- 
philic, and one can be sure whether or not a cell contains haemoglobin 
only when he sees it in the fresh state. A cell concerning which one is 
doubtful is more probably a leucocyte than a megaloblast, at least that 
is the safer view to take. 

Although megaloblasts occur most commonly in this anaemia they 
are nevertheless rare here, and even Ehrlich, it is said, would hunt for 
hours until he found this much desired cell upon which he would stake 
the diagnosis of an otherwise clear case. If after a long search one 
finds six or eight such cells, he should be more than satisfied, and in 
some cases none will be found at times, and many on a later occasion. 
Their presence in large numbers is rare and ominous. Their number 
varies from day to day, there being interims of improvement during 
which they are absent, reappearing during a relapse. In other cases, 
however, they have been found during these periods of intermission 
while the blood-count is fairly normal. It is sometimes necessary 
to hunt two hours for one such cell, and yet the importance of this cell 
justifies that trouble. Upon the percentage of these rests some prog- 
nostic value. In megaloblasts polychromatophilia and the basophile 
granulation are particularly well marked. 

Typical megaloblasts are found most frequently in pernicious 
anaemia, even in the mild grades, and for the diagnosis of these cases 
they are of great value. They occur rarely in other anaemias, except 
of children. They are present in bothriocephalus anaemia ; a few are 
found in cancer cases, especially those with metastases to bone-marrow. 
We have seen as beautiful ones as could be desired in simple tertian 
malaria without any marked anaemia, and they occur perhaps always 
in malaria of children. They occur in large numbers in splenomyelog- 
enous leukaemia ; in secondary anaemias and chlorosis very rarely. 
They would seem to occur especially in those conditions in which the 
bone-marrow is involved, and of these, apart from the anaemias, malaria 
is a good illustration. Some consider their presence an indication of 
the severity of an anaemia, not of its form ; others that it is a sign of 
bone-marrow involvement (by infection, new growth, etc.) ; others 
consider that large cells express an effort to increase the volume of 
haemoglobin-carrying protoplasm. Another explanation suggested for 



568 



CLINICAL DIAGNOSIS 



megaloblasts is that they are swollen hydrsemic cells, that is, are 
dropsical, and contain the increased water of the plasma. It is true 
that some, the so-called " chlorotic cells " do suggest this very strongly, 
but they are always paler in tint; in cases of marked hydremia there 
are often no such cells present, as, for instance, in nephritis, and they 
also occur in large numbers in chlorosis, and there the plasma is 
practically normal. 

Intermediate Forms (Plate I, 31, 37, and Fig. 113, b). — This is 
a most troublesome term. In some cases this group includes nearly all 
of the nucleated reds found in the blood. We have made it an invari- 
able rule that all cells suggesting megaloblasts and concerning which 
there is any doubt shall be put into this group. That is, a nucleated 
cell the size of a normoblast with the nucleus of a megaloblast, or a 
cell the size of a megaloblast with the nucleus of a normoblast, is 
assigned here, hence the group contains a great variety of sizes both of 
cells and nuclei. It is very evident to one studying the pictures of the 
blood cells of cases reported as pernicious anaemia that there is wide 
divergence in the use of the term megaloblast. This accounts for 
many contradictory statements as to their frequency. 

Whether these cells are intermediate between megaloblasts and 
normoblasts we do not know ; by the term we merely mean a cell con- 
cerning which we are in doubt. The existence of transitional cells has 
been denied by Ehrlich and Pappenheim. All transitions have been 
found by others (Schaumann). These occur in conditions in which 
megaloblasts would be expected, and we believe that their significance 
is practically the same. (See page 513.) 

Microblasts. — These cells have a nucleus the size of a normoblast, 
but the protoplasm is exceedingly scanty and often ragged on the 
margin. The nucleus is usually pycnotic. Whether these cells are 
derived from normoblasts as degeneration forms, or whether they are 
preformed and have the same significance as normoblasts, is not yet 
known. They occur in pernicious, also in severe secondary, especially 
the post-hemorrhagic, anaemias. 

The presence of nucleated reds was noted in 57 of 69 of our cases. In 13, 
definite blood crises were present ; that is, more than 50 nucleated reds per 1000 
leucocytes. This is rather an arbitrary line, and yet we have found that, in our cases 
at least, it corresponded quite well with the blood pictures. In all cases normoblasts 
occurred, while in 40 (58 per cent.), megaloblasts also. In the other six cases 
normoblasts and intermediate forms occurred. 

In these 57 cases there were 63 periods during which nucleated reds were 
present. Of these 63 periods, in 26 — that is, in 41 per cent. — there followed a 
gain in the red blood-cells ; in the rest, either no gain or a loss. Of 14 periods 
without nucleated reds, during 8 there was a distinct gain. 

In 13 of our cases (19 per cent.) blood crises were present. Five of these cases 
died. Of the 50 or more nucleated cells per 1000 leucocytes constituting the crises, 
the normoblasts varied from 5 to 3128; the intermediates reached even 212, and 
the megaloblasts 44. There seem to be two definite forms of blood crises, those 



THE BLOOD: PERNICIOUS AN.EMIA 



569 



in which normoblasts largely predominate and those in which the intermediate 
and megaloblasts are also present in considerable numbers. 

It is the normoblastic crises particularly which are followed by a rise in the 
red count ; those with many megaloblasts are less inefficient or occur in a condition 
of the bone-marrow when it cannot regenerate the blood. They appear especially 
when the patient is losing ground. 

The most remarkable blood crisis lasted for nineteen weeks. During this time 
the red blood-cells, at the beginning 1,902,000, rose to 2,562,000, and then finally 
dropped at death to 1,328,000. During this time the leucocytes varied from 3000 
to 5000 until the day of death, when there were 16,000. During the whole period 
the number of normoblasts per thousand of leucocytes was almost always above 
500, reaching on one occasion 1164, a little later 1032, and finally 3128. On this 
day the leucocytes were 4600 ; hence the total number of normoblasts per cubic 
millimetre was 14,388, of intermediate forms 460, and megaloblasts 138 per cubic 
millimetre. 

Haemoglobin. — The haemoglobin is much reduced, rarely above 50 
per cent., and often as low as 10 per cent. The color-index is normal 
or high, a point of the greatest importance in determining the nature 
of the anaemia. In our cases on admission the haemoglobin aver- 
aged 34 per cent., and the color-index in 80 per cent, of the cases was 
over 1, an average of 1.1, and in 2 cases as high as 1.9. 

Ewing considers that the index is low in the chronic cases and high 
in the acute. For it to rise is considered a bad sign, indicating as it 
does a falling count ; with improvement there is always a lowering of 
the index due to the newly formed cells, which are of lighter weight 
than normal. 

The high color index has received various explanations. Some say it is the 
result of abnormal " globular richness," by which they mean that the individual 
cells contain an abnormally large amount of haemoglobin, and this idea is confirmed 
by estimations made of the weight of the cells. Others say it is explained by the 
large number of macrocytes present, and the haemoglobin curve does run fairly 
parallel to the curve of the number of these large cells. Others ascribe it, and 
with good reason in some cases, to blood counts which are incorrect since they 
do not include a great many of the microcytes which are so easily overlooked, 
and yet which contain no small amount of haemoglobin. And, lastly, others say that 
in pernicious anaemia there is haemoglobin free in the plasma. Many believe that 
the chemical composition of the red blood-cells is not normal ; their nitrogen has 
been found increased (v. Jaksch), hence the name " hyperalbuminaemia rubra;" 
more iron is sometimes present than albumin to complete the haemoglobin mole- 
cule, which means that iron is either increased in the haemoglobin molecule, or is 
present in other combinations. Additional evidence for this is the haematogenous 
jaundice, and some have found iron compounds in the plasma, which may mean 
merely poor technic. Taylor considers the high color-index as an optical illusion ; 
Capps, that color-index never surpasses volume index; Grawitz (and this appeals 
to us very strongly) warns against haemoglobin determinations with an ordinary 
haemoglobinometer and emphasizes the error of overlooking microcytes in blood- 
counting. He considers that the best test of the index is the appearance of the 
cells, and thinks that the inequality in the distribution of protoplasm and 
the production of poor cells are the prominent features of pernicious anaemia. 
Benzancon and Labbe think that from their appearance one does not get 
the idea that the cells are overrich in haemoglobin. It is our opinion that they 
are. Many of the large cells in fresh specimens will be seen, when compared 
with normal ones, to be of a darker tint, but whether this tint is due to an 



570 



CLINICAL DIAGNOSIS 



increased amount of haemoglobin, to the greater optical thickness of a spherical 
cell, or to chemical changes of the haemoglobin, it is difficult to say, and per- 
haps all elements enter. These large cells show little biconcavity, and often 
appear somewhat biconvex. That changes in the haemoglobin can make the red 
blood-cells appear darker is illustrated by many degenerating cells, by cells picked 
up by phagocytes, and by the brassy cells of malaria. 

It is most important to remember that those haemoglobinometers with a color 
prism do not give accurate readings in the lower half of the scale unless they are 
standardized at various points along the prism, and an error of 5 per cent., so 
insignificant in normal blood, changes the index considerably when added to a total 
of 10 per cent. 

The haemoglobin during the course of our cases ran as a rule parallel with the 
red blood-cells. As the cases became worse the index slowly rose, and at death 
averaged 1.5. This may have been due to the tendency to form large cells. 

Leucocytes. — In severe and uncomplicated cases there is always a 
leucopenia. Cabot's average was 3800, and in 72 of no cases below 
5000. The leucocytes in our cases on admission averaged 4600. This 
includes all cases, even those with a leucocytosis due to complications. 
In 75 per cent, of the cases the count was under 5000. They may go 
as low as 1 500 or 2000, and sometimes before death as low as 500 per 
cubic millimetre. Their number runs parallel to that of the red blood- 
cells, as a rule. A leucocytosis means either a complication, as pneu- 
monia, some pus process, a blood crisis, in which case the large number 
of leucocytes may even suggest a leukaemia; and lastly, at death, the 
picture may be leuksemic (100,000). 

Very roughly the leucocyte count ran in our cases parallel to the red count, 
and at death varied from 660 to 16,000, and averaged 5950. 

Of our 81 cases, in 55 (70 per cent.) at some time during their stay the count 
fell below 3000; in 32 (40 per cent.), below 2000; in 9 (11 per cent.) it fell to 
1000 or below. The very low counts, 1000 or below, are found only in the severest 
cases. 

The percentage of polymorphonuclear neutrophile cells is roughly 
parallel to the total leucocyte count. This is best seen in the rise of 
these cells with the improvement of the case. Their percentage is 
lowest in the low counts, and the low count seems to be due to their 
diminution. 

The percentage of the non-granular mononuclear cells varies in- 
versely to that of the granular cells. The highest in our cases was 93 per 
cent. In the majority of the cases the percentage relation of the leuco- 
cytes tends to be constant whatever the total count of these cells, and in- 
dicates that these variations are due more to the distribution or dilution 
of the blood, perhaps stasis in the vessels, than to any real change in 
blood formula. On the other hand, there are considerable changes in 
total count, in which the absolute number of these mononuclear non- 
granular cells is quite constant. 

Toward death the percentage of these cells rises, probably because 
the granular cells are formed in diminishing numbers. It is interesting 



THE BLOOD: PERNICIOUS AN.EMIA 



571 



that the variations in the percentage of these cells show definite waves 
during the course of the disease. 

The relatively high lymphocyte count is seldom a true lymphocyto- 
sis, but is due to an absolute decrease in the polymorphonuclear cells. 
The average of small mononuclears is 45 per cent. It may reach as 
high as 62 per cent, and before death even 79 per cent., and yet the ab- 
solute number be normal. This has been considered evidence that these 
lymphocytes arise in the lymph-glands and not in the bone-marrow. 
This decrease in the polymorphonuclear cells is the important feature, 
and in diagnosis excludes often cancer and septic anaemia, yet in the 
same case the count varies so much that it is not of very much impor- 
tance. 

In 12 (17 per cent.) isolated counts there was a true lymphocytosis. 
This was maintained in no case for more than one or two counts. Two 
of these were cases with a definite leucocytosis, while in the other cases 
the total count was not above normal limits. Hence a lymphocytosis 
may occur, but is not a common feature. 

The eosinophiles averaged about 2.7 per cent. They may reach as 
high as 9 per cent., and are often absolutely increased. In extreme 
cases they may be diminished. 

The myelocytes may reach 2 per cent. Their presence is more con- 
stant and their number greater than in any disease except leukaemia. In 
acute exacerbations of the disease they may reach even 29.4 per cent, of 
a total of 34,000 cells (Billings). Eosinophilic myelocytes sometimes 
occur, but rarely. In 23 of our cases myelocytes were present in num- 
bers varying from 0.2 to 8 per cent. Nine of these cases were fatal. 
In 12 cases the percentage was not above 1 per cent. In 6 it was above 
3 per cent. 

In our cases the myelocytes occurred especially under two conditions ; in cases 
with a very low count, even the lowest, in which case their percentage was the 
highest ; for instance, of 1800 leucocytes, 8 per cent, were myelocytes. Again, they 
were much increased in cases with leucocytosis, as, for instance, a case with 14,400 
leucocytes and 2 per cent, myelocytes; another with 11,600 and 0.5 per cent, 
myelocytes. 

Mastzellen were present in 29 of our 69 cases. In 2 they were over 
3 per cent., but in 8 over 1 per cent. Of the other 21 cases the average 
was 0.5 per cent. If these high percentages were really of Mastzellen 
it would show that in pernicious anaemia they show a definite increase 
hitherto not mentioned. We doubt very much that this is the case. In 
our cases of pernicious anaemia, in none were differential stains for these 
cells used, and in this disease it is quite common to find polymorphonu- 
clear cells presumably of the neutrophile series without granules. So 
marked is this in some cases that it has been suspected that the body has 
lost its ability to form the neutrophile material (Ehrlich). This may 



572 



CLINICAL DIAGNOSIS 



explain their high percentage. As is well known, in using Ehrlich's 
stain most non-granular polymorphonuclear cells are counted as Mast- 
zellen. The high percentages occur always in cases with a low total 
count, the average of the above cases with over I per cent, being 
3900. 

Degenerated leucocytes are common; pale, swollen, and vacuo- 
lated, with the nuclei fibrillar. There is an increased number of neutro- 
phil granules in the periphery of some cells. Hayem considers that 
they will imbibe a certain amount of haemoglobin. Certain cases are 
reported in which the diagnosis between pernicious anaemia and acute 
leukaemia was said to be quite difficult; one, for instance (Williamson 
and Martin), in which the red blood-cells were 300,000, haemoglobin 
12 per cent., leucocytes 38,000, with the small mononuclears 99 per 
cent. ; Westphal's case, with 816,000 reds and 24,000 leucocytes; Bez- 
ancon and Labbe's, with 550,000 reds, of which 3520 per cubic milli- 
metre were nucleated, leucocytes 32,000, small mononuclears 66 per 
cent, (seepage 586). 

The absolute number of the eosinophiles is a splendid index of the 
course that the blood is taking, running in many cases parallel to that 
of the red blood-cells. During sixteen admissions there was a definite 
rise of these cells attending the improvement of the condition. 

In several cases, with little change in the condition of the blood, 
the number of these cells was fairly constant, while in 10 cases these 
cells fell as the red blood-cells dropped, in 3 being absent at the time of 
death, and almost so in 2 others. These cells may drop as the patient 
goes down hill, even though the red blood-cells do not. Some cases 
are exceptions, as, for instance, in 8 there was no rise in eosinophiles as 
the blood improved ; in 4 there was a rise, but without any accompany- 
ing improvement ; while in one count, a terminal pneumonia, these cells 
were 220 in number at death. The explanation of these exceptions, 
however, is not difficult. In cases in which with apparent improve- 
ment there was no rise of eosinophiles it is to be noted that the increase 
in red cells was particularly rapid, averaging 43,000 per day. In 5 
cases, with a considerable rise ending in a definite eosinophilia, the 
average gain of red cells per day (17,000) was slow, and lasted over 
a considerable period of time; while in those cases with a slight in- 
crease and not ending in a definite eosinophilia the rise in the red count 
was still more rapid, averaging 34,000 cells per day. This, we think, 
indicates that the slow rise of the red count over a considerable period 
of time is more surely due to new blood formation. The rapid changes 
in the red count may mean plasma changes, etc. 

The number of eosinophile cells may not run parallel to that of 
the red cells, but their large numbers occur chiefly in those cases which 
are doing well or after they have already done well ; that is, following 



THE BLOOD: CHLOEOSIS 



573 



a rise of the reds these cells may be increased. They are present in 
particularly large numbers in those cases gaining very slowly. 

A diminution in the absolute number of eosinophile cells may be 
of ill omen, as in one of our fatal cases. For fifteen days before death 
the red blood-cells remained constant ; that is, the first of six counts 
was 2,832,000, the last 2,704,000, and the average in all was 2,700,000. 
The absolute number of eosinophiles at first was 183, shortly after- 
wards 180, and toward the end there were none at all. 

Platelets. — The blood-platelets are decreased or even absent, often 
only one-twentieth the normal number. In other cases they are said to 
be increased (v. Limbeck and Sahli). Grawitz considers that they 
vary. Hayem found the count as low as 25,000 or even 15,000, per 
cubic millimetre. 

Coagulability is usually decreased. The blood from a venesection 
does not separate into clot and serum. 

Serum. — The changes in the plasma are important, since this con- 
stitutes 90 per cent, of the total blood. It loses very little of its 
albumin ; for instance, there is a loss of 50 per cent, of the albumin of 
the total blood yet of the serum of only 8 per cent. This is very dif- 
ferent, therefore, from the hydraemic anaemias after hemorrhage and 
those due to poor diet, in which the serum is most affected. It is an 
important diagnostic point also to exclude the anaemias of cancer and 
of sepsis (cryptogenetic infections). 

The 'specific gravity averages about 1030, and may go as low as 
1025. 

The solids of the blood average but about 9 per cent. The water is 
increased to even 90 per cent. The greatest loss is in the albuminous 
bodies, which are reduced even to one-third the normal. This is espe- 
cially due to the corpuscles, for the serum in the severe cases may be 
normal. In the plasma the serum globulin is alone decreased, serum 
albumin being practically normal. 

Chlorosis. — This is a disease especially of young girls at puberty, 
the essential blood-feature of which is a reduction in the haemoglobin. 
The count of red cells is almost normal ; the cells show few signs of 
degeneration or destruction ; the haemoglobin formation is very defec- 
tive, and there seems to be a polyplasmia. It is the only good illus- 
tration of anaemia due to defective haemogenesis. and differs from all 
other forms in the lack of evidence of blood destruction (v. Noorden), 
as shown by the poverty of the urine in pigment, the slight degenera- 
tion of the red blood-cells, and the absence of jaundice. Chlorosis is 
more a clinical than a blood picture, since this latter is well simulated 
by many secondary anaemias, for instance by the ordinary post- 
hemorrhagic form. We cannot make a diagnosis of chlorosis from 
the blood alone, since all secondary anaemias have some of its features. 



574 



CLINICAL DIAGNOSIS 



Yet clinically the picture is sharp, so sharp that some will diagnosticate 
chlorosis without blood changes (Laache). 

The blood features to be emphasized are : that in chlorosis there is a 
more uniform diminution in the size of the red cells, and a more uni- 
form paleness, while in the secondary anaemias, even of a severe grade, 
the red cells vary widely in size, and a good many will be normal in 
size and color; in chlorosis the color-index is lower, a lymphocytosis 
more common, the nucleated reds more infrequent, and coagulation 
more rapid than in secondary anaemias. 

The gross appearance of the drop is very pale, thin, and watery, 
and the blood clots rapidly. 

The count of the red blood-cells need not be very much reduced, 
and yet in over 60 per cent, of the cases it is under 4,000,000 cells at 
the first visit (Reinert, v. Limbeck). Thayer's average of 63 cases at 
the first visit is 4,096,000; Cabot's, 4,112,000; Graber's, 4,482,000, 
while Grawitz's cases varied from 3,400,000 to 4,300,000. The mini- 
mum count of Cabot's was 1,932,000; of Thayer's, 1,953,000, and of 
Hayem's, 937,360. Graber, who claimed that in simple chlorosis there 
is no diminution in the count, which would indicate a complication, 
cites a maximum of 5,700,000 cells. Low counts are rare, and some 
complications may always be suspected, as ulcer of the stomach. The 
color of the red blood-cells indicates a marked diminution of haemo- 
globin, their biconcavity is pronounced, the pessary form of cells 
common, and the cells stain very poorly (Plate I, 23, 24). 

There is a quite uniform diminution in the size of the cells, and yet 
the large, pale, so-called " chlorotic cells" bring the average up to 
almost normal, the cells varying from 5.2 to 11.5 microns in diameter,, 
with an average of 7.5. These large chlorotic cells are interesting, since 
many consider that they are dropsical cells, — that is, cells swollen 
because of the water they have imbibed from the plasma ; and yet their 
number is usually few and the great majority of cells are almost uniform 
in size, and a little smaller than normal. There is not the large admix- 
ture of normal cells seen in secondary anaemia. Macrocytes are rare. 
Microcytes are more common. Schaumann and Willebrand say that at 
the height of the disease the small cells predominate, while during con- 
valescence the large cells. Grawitz says the cells are largest when the 
case is at its worst. These large chlorotic cells may be very numerous, 
even one-third of all, at the height of the disease. 

Poikilocytes and degenerated cells are rare except in the severer 
cases, and the polychromatophilia is considered by many to mean youth 
of cells, and, therefore, to be a sign of active regeneration (Graw- 
itz). " The granular degeneration does not belong to the picture of 
chlorosis, but means some complication." Stengel and Pepper think it; 
common. 



THE BLOOD: CHLOROSIS 



575 



Nucleated reds are very rare except in the severer cases, or during 
improvement, when blood crises may occur, although this is denied by 
some. They are much rarer than in the secondary anaemias. They 
are usually normoblasts, seldom megaloblasts. 

Haemoglobin. — It is the reduction of the haemoglobin which is the 
characteristic feature. This may be reduced to even 20 per cent. 
Cabot's average on first visit was 41.2 per cent.; Thayer's, 42.3 per 
cent. The color-index is, therefore, low, averaging 0.5, but in some 
cases it is as low as 0.3. Secondary anaemias never reach this level. 
The cause is the small amount of haemoglobin in each cell and the large 
numbers of small cells. The volume of the red blood-cells is just about 
half the normal. 

The average leucocyte count in Thayer's cases was 8467; in 
Cabot's, 7485 ; that is, the count is normal ; a leucopenia is not uncom- 
mon. This is important in diagnosis, since in the secondary anaemias, 
especially those of cancer, there is usually slight leucocytosis. During 
the convalescence the leucocytes may increase more rapidly than the 
red cells, and there may be even a leucocytosis. 

Grawitz and v. Limbeck say that the blood formula is normal. 
Most observers, however, even in mild cases, find the small mononu- 
clears about 33 per cent. There is a- slight absolute diminution in the 
neutrophile cells, and among them may be found cells approaching 
myelocytes, but typical myelocytes are very rare. The eosinophile 
cells are usually somewhat increased, averaging 3.5 per cent., and in 
some cases even 9.6 per cent. 

During the last five years there have been admitted to our female wards but 13 
cases diagnosed as chlorosis. Of these, but 2 were at puberty, and the rest from 
seventeen to twenty-five years old (relapses?). Of these, the lowest count was 
2,600,000, the highest 4,000,000, the mean 3,700,000. Haemoglobin, 26 to 49 per cent. 
Color-index, 0.36 to 0.63; mean, 0.47. 

Leucocytes ; lowest, 2400 and 3800 ; between 5000 and 7000, 6 cases ; highest. 
8000. 

Differential counts made in 7 cases, all practically normal (even in the case 
with a total of 2400, there were: small mononuclears, 17.2 per cent.: large mono- 
nuclears and transitionals, 3.9 per cent.; polymorphonuclears, 77.1 per cent.; 
eosinophiles, 1.8 per cent.). 

It is interesting that when they left the hospital all (9 cases thus examined) 
had gained practically the same, between 900,000 and 1,711,000 cells; mean, 
1,100,000. 

The reason why we now see so few typical cases of chlorosis is a 
mooted question, but we suspect it is the vast increase in the use of 
patent medicines which contain iron. 

The platelets are increased, as a rule ; in fact, in no condition are 
they as numerous as in chlorosis. They also are large in size. 

The specific gravity of the blood is low, sometimes reaching 1030. 
This is due to- the loss of haemoglobin, and in this disease alone does the 



576 



CLINICAL DIAGNOSIS 



specific gravity run parallel to the haemoglobin content. Grawitz states 
that it varies from 1035 to 1045; others put the figures at 1030 to 
1050. Grawitz says that if it is under 1035 there is some complication. 

The alkalinity of the blood is normal. 

The isotonicity of the cells is low. 

In the serum there is very little change, since there is no blood de- 
struction, a feature which usually affects the plasma first. There is no 
hydremia in chlorosis, yet the total plasma seems increased (poly- 
plasmia). As the case improves, the number of the reds rises rapidly 
to normal; that is, "the anaemia is first cured" (Graber), then more 
slowly are these light-weight cells replaced by those more normal in 
size and shape and in haemoglobin content. Yet tnese variations in the 
count need not mean a new formation of cells alone, since the plasma 
changes must not be neglected ; in fact, the first sign of improvement 
is an increase of specific gravity and an increased count due to the dis- 
appearance of some of the plasma, as shown by the polyuria and the dis- 
appearance of oedema. Later the signs of regeneration appear, also the 
gradual elimination of the faulty cells, the appearance of more normal 
ones, and the rise of leucocytes to even above normal. 

Leukaemia. — Leukaemia is a disease marked by the constant pres- 
ence in the blood of granular mononuclears or an increase of the non- 
granular cells with round nuclei, the immature cells of the blood- 
building organs which are not normally present in the peripheral blood. 
The blood formula is markedly changed. There is, as a rule, also a 
great increase in the total number of the leucocytes, and yet during 
the periods in which the count is normal the diagnosis can often be 
made from the large numbers of these abnormal cells present. 

Leukaemia is rated among the primary anaemias, although the dimi- 
nution in the red count is not an essential feature. The reason perhaps 
for the emphasis upon the anaemia is the old view that these white 
cells were immature red cells which had failed to develop haemoglobin 
(Virchow). Interestingly enough, for certain cases of acute leukaemia 
there is now a reversion to this idea by some writers, the similarity in 
shape of the normoblasts and the lymphocytes, and the percentage rela- 
tions both in the marrow and in the blood indicating that perhaps the 
mother cell of both is increased and produces the white cells chiefly. 71 
Apart from this, the cachexia, which always arises sooner or later, is a 
very important feature of the disease. 

Anatomically, it is a disease with lesions of the haematopoietic 
organs only. Formerly it was the pathological picture which was the 
most important, then the blood picture; as a fact, both are important, 
since the latter is not the disease, but a symptom of the former. 

According to the blood picture three forms may be separated : 
71 See Reed, Amer. Jour. Med. Sci., October, 1902. 



THE BLOOD: LEUKAEMIA 



577 



(1) Lymphatic leukaemia, ki lymphsemia," in which the increase is 
of the non-granular cells. 

(2) Splenomyelogenous leukaemia, " myelaemia," or "true leukae- 
mia,' ' with an absolute increase of all forms, but especially with the 
presence of the mononuclear granular cells. 

(3) Mixed leukaemia, in which both the granular and non-granular 
mononuclear cells are increased. 

Of all three forms may occur cases of acute leukaemia (see page 

586). 

Whether the disease is a disease of the lymph-glands on the one hand, and 
the bone-marrow on the other, or whether both non-granular and granular cells 
arise in the marrow alone, is a question for the physiologists to decide. From a 
haematological point of view it is to be emphasized that the abnormal cells are 
always young forms ; that for many of the non-granular, mononuclear cells the 
name lymphocyte is a misnomer ; that in the myelogenous and mixed leukaemias 
all forms of leucocytes are involved ; and it is only in the so-called lymphatic 
leukaemia that one group alone is increased. 

Leukaemia differs from leucocytosis not so much because of the 
higher white count as of the presence of large numbers of these 
unripe cells, and also of its chronicity. In the intermissions the diag- 
nosis can often still be made from the differential count. 

There is a tendency now to group all forms in one, and pathologi- 
cally this may be justified, but not clinically, for there the line is gen- 
erally quite sharp between the myelogenous and lymphatic forms, 
although some (Wolf especially) 72 claim to have demonstrated the 
transition from a lymphatic to a myelogenous type, and the reverse 
change seems to be even more common. In claiming such transitions, 
Wolff insists that cases in children must be excluded ; a coexistent 
leucocytosis and lymphatic leukaemia must be thought of ; and consid- 
ers that one may recognize non-granular myelocytes. Grawitz sums 
up the question thus : that leukaemia is one disease, with various symp- 
toms and various blood pictures, and with but one law, and that is its 
lawlessness. 

Splenomyelogenous Leukaemia (Plate I). — In this disease there 
is a marked increase of all the granular cells, especially neutrophiles, 
also of eosinophiles and basophiles, and especially of the young forms 
of these cells with spherical or but slightly indented nuclei. The non- 
granular cells are also very much increased. 

Total Blood. — In many cases of this form of leukaemia there is 
certainly an increase in the total volume of blood, as is shown before 
death by the dilatation of the veins, as well as at the autopsy table. 
Later on, however, in other cases, as death approaches, a diminution in 
the total blood volume seems to occur. 



37 



72 Zeit. f. klin. Med., 1892, vol. xlv. 



578 



CLINICAL DIAGNOSIS 



Grossly, the blood looks normal even when the leucocytes are 
almost equal in number to the red blood-cells. In extreme cases it has 
a pale, more opaque look, and flows sluggishly. Cases have been de- 
scribed in which the fresh drop resembled " chocolate mixed with 
cream." This must be very rare, as so many have never seen it. It is 
probably due to haemoglobinaemia. When making smears the blood 
seems thick; hence it is hard to get good preparations (which appear 
granular) ; the diagnosis has often been made in this way. If the 
blood be allowed to settle and coagulate, there will form a grayish- 
white layer on the top of the clot, which may suggest the diagnosis. 
Coagulation is slow, and in the severe cases sometimes absent. 

Red Blood-Cells. — As a rule these are diminished (Grawitz said 
always unless some factor concentrating the blood was present). In 
Taylor's cases there were none above 4,000,000. Very rarely is the 
count normal; very rarely is it much diminished, although in some 
cases it is. The cachexia, slight jaundice, increased urinary pigment, 
and the deposit of iron in the various organs show that a toxic 
haemolysin is present. Cabot's average count was 3,120,000 ; Osier's, 
2,850,000. In 9 recent cases with 11 admissions, the lowest count was 
1,640,000 ; the highest, 3,800,000 ; mean, 2,800,000. As the leucocytes 
increase the reds decrease, and vice versa. There are exceptions, 
however, and the count may remain almost normal for a long time, 
some cases at 5,000,000. The anaemia may be due partly to the 
hemorrhages, which are so common, or to the albuminuria and the 
diarrhoea. The count may be almost as low as in pernicious anaemia, 
and attention is called to the fact that this oligocythemia persists 
during those periods at which the leucocyte count is normal and the 
patient feels better. If the patient is seen for the first time at this 
period, the diagnosis of pernicious anaemia would certainly with justice 
be made (Taylor). The subjective condition of the patients depends 
little on the count of red cells, since they are ready to go home when 
this has changed but little. 

Qualitative Changes. 1 — The anaemia is of the chlorotic variety, 
the cells being pale, w;ith little haemoglobin. This is best seen if 
stained with indulin or nigrosin. There is remarkably little degenera- 
tion, although the endoglobular areas do occur. Microcytes and ma- 
crocytes are rare; poikilocytes occur in all cases, but not many as a 
rule. The polychromatophilic degeneration and the basophilic granules 
are common, yet are never very numerous, and, in some severe cases the 
reds are normal. Biermer's test was found positive in two cases. 

Nucleated Reds. — These cells are remarkably numerous consid- 
ering the mild grade of the anaemia ; in fact, this is the condition par 
excellence in which to study them, as there is no disease in which 
normoblasts occur more constantly ; yet their absence is not against 



THE BLOOD: LEUKiEMIA 



579 



this diagnosis. Megaloblasts are found in many of the cases, and in 
some are quite numerous. The same is true of gigantoblasts, which 
may reach a diameter of 20 microns. This megaloblastic feature of 
the blood while marked in leukaemia is not so much so as in pernicious 
anaemia. Microblasts also occur. Karyokinetic figures in all stages 
of division are best studied here. Of Taylor's 16 cases, in 2 the num- 
ber of nucleated reds varied from 60,000 to 70,000 per cubic milli- 
metre, and one of the first effects of the arsenic was to. reduce the 
number of these cells. Before death there may be but few, or there 
may be an increased number of these cells. It is of interest that marked 
rises in the white count are accompanied by rises in the number of 
nucleated red cells. 

The haemoglobin is reduced, the color-index being about 0.6. 
Osier's average of haemoglobin was 42 per cent. In 9 recent cases the 
mean was 30; index, 0.54. The haemoglobin is hard to estimate, since 
the leucocytes render the blood so opaque. 

Leucocytes. — From the appearance of the fresh specimen the diag- 
nosis may sometimes be made at a glance, not so much because of the 
large number of leucocytes as the large number of immature cells 
which are never present in normal blood. One may have a simple 
leucocytosis with the count as high as it is in some cases of leukaemia ; 
in some cases of leukaemia the count is normal ; and some post-febrile 
cases have a blood formula which for a time suggests leukaemia. 

Counts of 500,000 are not rare. Cabot's average at the time of the 
first visit was 438,000 ; Osier's, 298,700. The counts vary, yet not as 
much during one admission as would be supposed, the daily counts 
maintaining approximately the same level for weeks, and during the 
same clay we*have not seen the great variations spoken of (e.g., on one 
day the blood was counted each four hours : 146,000, 134,000, 141,900, 
143,200). Some are cases with quite uniformly high counts — over 
400,000; but the most have moderate counts, — from J 00.000 to 300,- 
000 (63 per cent, of 51 cases), while fewer are below 100,000. One 
case may belong at different times to each of these groups, but during 
a hospital admission it keeps in one group. There are periods w T hen 
the count is normal, yet even then the differential count will usually 
give the diagnosis. (In three of Taylor's cases there were no qualita- 
tive changes. ) In some other conditions neutrophile myelocytes occur, 
but not with increased eosinophils and basophiles ; mononuclear eosin- 
ophils are rare in other conditions. 

Differential Count. — All the cells of normal marrow appear in 
the blood. Among these the neutrophile myelocytes in enormous num- 
bers are the predominating cell. The very large myelocytes occur, 
with a large chromatin-poor nucleus which stains palely, is hard to 
make out, and is often in an eccentric position ; these cells are seen only 



580 



CLINICAL DIAGNOSIS 



in this and in some diseases of children; they are sometimes even 30 
microns in diameter (Cornil's myelocytes). Also smaller myelocytes, 
about the size of an ordinary leucocyte and with a centrally placed 
round nucleus which stains well, are seen. Lastly, dwarf myelocytes 
about the size of red cells occur. All transitions between these largest 
and smallest myelocytes may be found. Mitoses are more or less 
common. The number of granules in these cells varies considerably, 
some being full, in others there are a few, and still other cells are 
confusing, since different persons will not agree as to whether they are 
granular or not. Grawitz emphasizes the large non-granular cells, 
some of which are very large, with a homogeneous body and a large 
pale nucleus which is often seen without protoplasm, and which break 
up rapidly ; others are medium sized, with basophilic protoplasm stain- 
ing intensely, and a medium-sized nucleus ; in other similar cells be- 
ginning granulation can be seen. These are the transitional forms of 
myelocytes. There are also myelocytes about the size of a leucocyte, 
with rather small compact nuclei. This is the form seen in inflam- 
matory leucocytosis. 

Eosinophile myelocytes are found, sometimes in large numbers, 
but they are never as numerous as the above. There also occur all 
transitional forms between these and eosinophile leucocytes. 

Polymorphonuclear Neutrophils. — While these are relatively di- 
minished (Cabot's average 46 per cent.), their absolute increase is 
considerable, even to about 50,000. Anomalous cells are common, 
some very large, even 20 microns in diameter, some small, or dwarf 
cells, 4 microns in diameter, a variation in size which never exists in 
leucocytosis. Again, cells with unusually shaped nuclei occur, and 
cells with more than one form of granule. The granules may vary 
in tint, which depends partly on the method of fixing; in one case all 
cells were described as non-granular. Free granules from the many 
cells which have broken down can be found in the plasma. 

Lymphocytes. — The percentage of these cells is reduced, the aver- 
age being 10.6 per cent., but usually there is an absolute increase. 
These cells vary much in size, and among them are some which it is 
very difficult to tell from myelocytes. One finds also the large mono- 
nuclear cells which are common enough in the marrow, but which 
never reach the blood normally or in other diseases. Some have very 
irregular shapes, some a few granules. 

The large lymphocytes have a scanty ragged protoplasm and a large 
chromatin-poor nucleus. These are Frankel's unripe cells, supposed to 
be characteristic of acute leuksemia, but occurring also in the chronic 
types. Large mononuclears, both those of the normal blood and those 
mistaken for myelocytes, occur in large numbers. Of the latter the 
nucleus is often very basophile, the protoplasm is finely fibrillar, and 



THE BLOOD: LEUKAEMIA 



581 



distinctly basophilic or acidophilic. These cells before the Ehrlich's 
stain was used were reckoned as myelocytes. 

Large phagocytes (splenic cells?) are sometimes present, number- 
ing in one case 1.2 per cent, of the leucocytes (total count 216,000). 

Eosinophiles. — In this disease there is usually an absolute increase 
of these cells. Ehrlich, indeed, stated that he would not make the 
diagnosis of leukaemia unless an absolute count of more than 250 cells 
was present. Since then three cases at least have been reported 73 of 
undoubted leukaemia, but at times without a single eosinophile cell, 
and others with extreme fluctuations in their numbers. As a rule the 
minimal number in leukaemia is about 3000, the average percentage 
5.1, and the average absolute number 11,000. These cells occur in all 
modifications like their neutrophile analogues, the large myelocytes 
(formerly said to be the characteristic cell), the medium-sized ones, the 
dwarfs, and the ordinary leucocytes. The eosinophile myelocytes may 
in this disease form the majority of the eosinophile cells. 

Basophiles. — Ehrlich considered that there was always an absolute 
increase of the Mastzellen in leukaemia, and that this was the only con- 
dition in which they were increased. Their absolute increase may be 
above that of the eosinophiles, and is always proportionally higher. In 
one of Lazarus's cases they reached 47 per cent. ; in one of Cabot's, 10 
per cent., while Taylor mentions a case with an absolute count of 
basophiles of 140,000. Taylor also states that in two cases no Mast- 
zellen were present. 

Charcot-Leyden crystals may be found in the blood after it has 
stood for a while, but also in the fresh blood, as was shown by splenic 
puncture. Some observers, however, including v. Limbeck and v. 
Jaksch, have never found them. They are normal in the bone-marrow 
and are present wherever the eosinophile cells are increased. Bez- 
ancon and Labbe say that leucin spherules also will separate sponta- 
neously. 

Ehrlich considered that from the examination of the smear alone 
the diagnosis of this form of leukaemia could be made. The six points 
which he emphasized were : the presence of neutrophile myelocytes ; 
eosinophile myelocytes ; an absolute increase of eosinophiles and of 
Mastzellen ; the presence of atypical cells, among which are dwarf 
eosinophiles and neutrophiles, both mononuclear and polynuclear ; cells 
in mitosis ; and, lastly, the large number of nucleated reds. As men- 
tioned above, however, the absolute number of eosinophile cells is no 
necessary part of the blood picture. And, indeed, any one of these 
points may fail for a while, at least. 

A great many of the leucocytes show signs of extreme degenera- 
tion. Ewing considers that eosinophile myelocytes with granules of 
73 See Simon, Am. Jour. Med. Sci., No. 125, 1903. 



582 



CLINICAL DIAGNOSIS 



very unequal size and density of stain are pathognomonic of myelo- 
cythsemia. In some cases the protoplasm is swollen, hyaline, or vacuo- 
lated. Nuclei surrounded by granules scattered widely through the 
plasma, the protoplasm evidently having disappeared, are very common 
pictures. In the nuclei, karyolysis, vacuolation and karyorrhexis are 
common ; pycnosis perhaps less so. Degenerated leucocytes are always 
present in leukaemia. 

In the diagnosis the point upon which emphasis was formerly laid 
to distinguish it from an extreme leucocytosis was the large number of 
white cells. This distinction does not in the least hold, since there are 
periods of leukaemia with a count normal or even subnormal, and yet 
during this time the formula may be that of leukaemia. The presence 
of myelocytes alone does not give the diagnosis, since in cases of ex- 
treme leucocytosis a few myelocytes will usually be present. These 
myelocytes, however, are usually about the size of the ordinary leuco- 
cyte, and are never the very large cells which occur in leukaemia ; also 
eosinophils and Mastzellen are not increased. The diagnosis is espe- 
cially difficult in children. In some cases autopsy alone will decide it. 

A recent case on first admission had 443,000 leucocytes; was re- 
admitted in fourteen months with a count of 9700'; the count remained 
low till his discharge twenty days later with 100,000. On the day with 
the lowest count, 6000, the differential was: s. m., 3.8 per cent. ; 1. m. 
and tr., 3.6 per cent.; pm. n., 70.8 per cent.; eos., 3.8 per cent.; 
neutroph. myeloc, 8 per cent.; Mastzellen, 7.6 per cent.; normo- 
blasts, 23; intermediates, 15; megaloblasts, 5 (per 1000 leucocytes). 
Hence even at this time a diagnosis could have been made. 

Variations in the count are extreme over long periods of. time ; the 
daily variations are sometimes considerable, as in one case reported, 
with 122,500 at ten a.m., at four p.m. on the same day the count 
was 235,000. 

With improvement in the condition the count may drop almost to 
normal. At this time the formula should help in the diagnosis, and 
yet this is not always true, since in some cases the characteristic blood 
picture has entirely disappeared. During such a period it would be 
impossible to differentiate a case with low red count from one of per- 
nicious anaemia by the blood alone; and, indeed, there are cases re- 
ported of a transformation to pernicious anaemia and vice versa. 
Following the long-continued use of arsenic the count drops in a 
remarkable way, to rise at once after the drug is discontinued. Turk 
mentions a case 74 in which the leucocytes ranged from 258,000 to 
370,000. After arsenic treatment they fell to 3000 to 6000 (0.5 per 
cent, myelocytes, 6.6 per cent. Mastzellen). It is a question how much 
improvement this indicates, as it may be an " exhaustion" of the bone- 

74 Deut. med. Wochenschr., 1904, No. 50. 



THE BLOOD: LEUKAEMIA 



583 



marrow. Following X-ray treatment remarkable drops have been 
reported, even from 693,000 to 6300 ; the leukemic character, how- 
ever, was never lost. The red cells rose to nearly double in this case 
(Joachin and Kurpjuweit). 

The infectious diseases which are survived, and this is rare, have a 
remarkable effect not only on the blood picture but also upon the blood- 
forming organs. This is particularly true of typhoid fever, influenza, 
miliary tuberculosis, ct al. Chronic tuberculosis has very little influ- 
ence. In Dock's case, 75 due to grip, the cells fell from 367,000 to 5000, 
then in six weeks returned to 157,000, and in one year to 461,000. The 
fall is sometimes extreme, as from 40,000 to 470. Some cases preserve 
the leukaemic formula, others do not. During the acute infection, when 
the count falls almost to normal, there is also a remarkable reduction 
in the size of the blood-building organs, and both sometimes return to 
their former condition in a few days after the infection is past; but 
not always, as in a case reported by McCrae ; and others are on record 
in which at autopsy all signs of leukaemia had disappeared from the 
bone-marrow. In other cases, however, there is a rise instead of a fall, 
as in Midler's case of sepsis the leucocytes dropped from 246,900 to 
57,300, then rose; in v. Limbeck's case of pneumonia they fell from 
140,000 to 43,500, and then, as the other lung became involved, rose 
to 172,000. As the count drops the percentage of polymorphonuclears 
rises, the picture thus approaching that of a leucocytosis. 

Late in the disease there may be a marked predominance of the 
large non-granular leucocytes, and there is good reason for the opinion 
that some of these are myelocytes without granulation, as if the body 
had lost its power to form the neutrophile material (Ehrlich). 

Platelets. — In this form of leukaemia the platelets are markedly 
increased, even reach their maximum. 

The water content is increased to 81 to 88 per cent. 

The specific gravity is low, even 1036; that of the plasma about 
normal. 

The alkalinity is somewhat decreased by the organic acids formed from the 
breaking down of leucocytes. Formic, acetic, lactic, and succinic acids have been 
found in the plasma. The xanthin bodies of the plasma are increased. Deutero- 
albumoses have been found. These are not present in lymphatic leukaemia, and 
are supposed to be digestive products of the leucocytes from a ferment provided by 
the polymorphonuclear cells. Taylor says that the nitrogen of the leucocytes is 
almost double. Nucleo-albumin is found in the serum, and uric acid, 22.6 mg. per 
100 cc. Coagulation is increased, in one case so much so that the red blood-cells 
could not be counted with a pipette. 

Lymphatic Leukaemia (Lymphaemia) (Plate II, A, B, C). — In 
this form of leukaemia is a marked increase of the mononuclear non- 

75 Am. Jour. Med. Sci., 1904, vol. cxxvii., a very exhaustive study of this subject 
with a review of 50 cases. 



584 



CLINICAL DIAGNOSIS 



granular cells. Despite the name, these cells are not all lymphocytes 
even in morphology, to say nothing of origin, but are mononuclear, 
non-granular cells of many sizes and forms. As a rule, while a variety 
of such cells are present, there is usually a predominance of one partic- 
ular size ; in some cases, the small mononuclear cells with a very nar- 
row ragged rim of protoplasm; in others the cells are all of the large 
lymphatic type ; in other cases the majority of the cells resemble the 
transparents, and in still others the transitionals of Uskow. In some 
cases the protoplasm of these large cells is basophilic; in other cases 
it is distinctly acidophilic; sometimes enormous cells are found. 

As a rule there is proliferation of the lymphatic tissue of the body, 
and yet this is not always evident, as is seen in some cases in which 
there are no palpable lymph-glands. In some of these cases- there may 
be considerable proliferation of the large masses along the intestines ; 
in still other cases the lesion seems limited to the bone-marrow. Some 
interesting cases begin with a great enlargement of the lymph-glands, 
the blood picture appearing later and coincident with it a diminution 
in size of these glands. This was true of a patient who in September 
showed normal blood and a general enlargement of the lymph-glands. 
The following January he was readmitted with a leucocyte count of 
110,000, chiefly the small cell variety. It is possible that the leukaemia 
does not begin till the disease of the lymph-glands has reached the 
marrow (Pappenheim). 

Red Blood-Cells. — There is a much greater anaemia in this form 
than in the splenomyelogenous, and yet here also the count may remain 
normal for some time; later, however, cachexia with anaemia begins. 
In two of the chronic cases the count remained above 4,000,000 during 
a long stay in the hospital and until death. A remarkable case is re- 
ported (verbally) by Dr. Hazen, of eighteen months' duration, with 
reds 960,000, leucocytes 250,000, nearly all of the small lymphocyte 
variety. Cabot's average on first admission was 2,730,000; Osier's, 
2,294,000; the average given by Hirz and Labbe is 1,829,000; by 
Petit and Weil, 1,292,000. The greatest reduction occurs in cases 
which show at autopsy the bone-marrow most involved, and in the 
acute cases, and the more acute the case the less the glandular enlarge- 
ment. Nucleated reds are rare, sometimes absent, yet in the very se- 
vere cases there may be as many as in the splenomyelogenous variety. 
In one of our cases, with a total white count of 12,000, there were 150 
normoblasts, 169 intermediates, and 20 megaloblasts per 1000 leuco- 
cytes, — a typical megaloblastic crisis. V. Limbeck describes them as 
astonishingly scarce. 

The red counts remain very constant, often despite great fluctuations in the 
white cells (e.g., 2,640,000 red cells, 105,000 leucocytes; in nine days 2,750,000 



THE BLOOD: LEUKAEMIA 



585 



reds and 328,800; two weeks later, 2,892,000 reds, 410,000 whites; and again in two 
days, 2,028,000 and 480,000 whites). 

In a case with pleural and ascitic fluids (chylous) repeatedly tapped, with pro- 
fuse diarrhoea, and finally death from streptococcus septicaemia, the white cells 
showed very slight variations. They were 133,400 on admission, rose to 242,000, 
and at death numbered 133,000 ; the red cells were often above 5,000,000. They 
were 4,912,000 on admission and 5,340,000 at death. 

The haemoglobin is diminished, Osier's average being 37 per cent. 

The leucocytes are increased, on an average to 144,800 (Osier) or 
141,000 (Cabot). In this form also there may be aleukaemic periods, 
which may last even six months. Jnst before death the count usually 
rises. One of our cases during the last ten weeks before death had a 
leucopenia of even 1900 cells. The count may be as high as in the 
myelogenous form, but this is rare. 

Differential Count. — Grawitz classifies the cases as, those in 
which the small mononuclears predominate ; those with a predominance 
of medium-sized cells with basophilic homogeneous protoplasm; and 
those in which the cells which predominate are very large and are for 
the most part degenerated. Yet all these forms may occur together 
in varying percentage in the same case, and vary at different stages. 
Roser thinks that in cases in which the lymph-glands are particularly 
involved it is the smaller cells which are increased, e.g., 99 per cent, of 
117,000; and in those in which the lesion is particularly of the bone- 
marrow, the larger cells. Grawitz mentions an increase of the larger 
cells as simultaneous with a decrease in size of the lymph-gland. 
These mononuclear cells are often 90 per cent, of the total number, 
even 98 per cent., and in one of Osier's cases 99 per cent. A marked 
feature of the blood picture is the degeneration of these leucocytes. 
During the course even 10 per cent, and just before death even 75 
per cent, may show some sign of degeneration, either of the proto- 
plasm, or pyenosis and fragmentation of the nucleus. It is inter- 
esting that so few cells in the blood show mitotic figures, while in the 
bone-marrow the proliferation is very active. Many lymphocytes are 
very small, often even smaller than red blood-cells. They stain faintly 
in Ehrlich's stain, deeply in methylene blue; the protoplasm is scarcely 
seen, or is ragged and degenerated, the nuclei are round or indented, 
and even fragmented, with a sharp margin, and contain clear areas. 
Wolff thinks we should separate lymphatic from lymphoid leukaemia, 
the former being of lymph-gland origin, the latter myelogenous. 

Polymorphonuclears are rare. Eosinophile cells are noticeably 
absent. In a pure case myelocytes are not present, although it is 
hardly wise to call the case mixed leukaemia if one be found. Mast- 
zellcn are absent, as a rule. In this form of leukaemia an acute infec- 
tion may cause a drop of the total count or a true leucocytosis. Au- 
topsy has shown the leukaemia cured. As a rule, even when the 



586 



CLINICAL DIAGNOSIS 



count is low, the mononuclear cells will be 90 per cent. Wende's case 76 
is a good illustration. The result of a streptococcus infection was a 
drop from 45,000 to 1600 leucocytes, but of small mononuclears from 
95.3 per cent, to 88 per cent. The result of an acute infection is some- 
times the appearance of a few myelocytes. Other cases show a marked 
increase in the count, as in Miiller's case of chronic septicaemia it rose 
from 180,000 to 400,000. 

In one case in this clinic the man was admitted with double tertian 
malaria and a lymphatic leukaemia of 105,000 (small monos., 83.6 per 
cent. ; large monos. and tr., 7 per cent. ; pm. n., 5.8 per cent. ; eosinoph., 
0.2 per cent.). One week after the malaria was cured the count rose 
to 328,000 and two weeks later to 480,000, with 97.2 per cent, small 
mononuclears. At this time there were 3 normoblasts, 3 intermediates, 
and 4 megaloblasts per 1000 leucocytes. 

V. Limbeck considers that the blood picture alone is not enough 
for a diagnosis, since in some cases of sarcoma the blood presents a 
similar picture. 

Acute Leukaemia. — This form of leukaemia, which has of late at- 
tracted a great deal of attention, is characterized by the brief course, — 
from six days to nine weeks (leukaemia acuta et acutissima), — the 
severity of the symptoms, the frequency of the hemorrhagic diathesis, 
the rapidly developing cachexia, and death. It occurs chiefly in young 
persons. The great majority of the cases are of the lymphatic type, 
but a few of the myelogenous variety have recently been reported ; 
other cases are best described as mixed. The cases of the acute myelo- 
genous form are collected by Gardinier, 77 who reports one and reviews 
eleven others, and also two doubtful cases (see also Billings and 
Capp). 78 

In all cases the anaemia is extreme, even below 1,000,000 red cells, 
and in Arneth's case 256,000 reds and 10 per cent, haemoglobin. 

The cases of acute lymphatic leukaemia are well reviewed by 
Rosenburger, 79 and acute leukaemia in children especially by Church- 
ill, 80 who reports one case and reviews 28 others. The disease occurs 
even in the new-born child. The lowest red count was 750,000, after 
a severe hemorrhage. The leucocytes varied from 6000 to 810,000 
(in a twenty-month-old child). The lowest counts came always just 
before death, which a falling count portends. Of these 29 acute cases 
in children, 25 were lymphatic (2 of the small-celled type, 3 large, 1 
mixed) ; myelogenous, 2 mixed, 1 uncertain. Churchill's case had 99 
per cent, small mononuclears, and many of them degenerated. The 

76 Am. Jour. Med. Sci., vol. cxxii., 1901. 

77 Johns Hopkins Hosp. Bull, October, 1904. 
7S Am. Jour. Med. Sci., 1903. 

79 Ibid., 1904, vol. cxxviii. p. 583. 
s0 Ibid., 1904, vol. cxxviii. 



THE BLOOD: LEUKAEMIA 



587 



anaemia is profound. It is of interest that the more acute the case the 
less the enlargement of lymph-glands and spleen. A good illustration 
is Pfannkuch's case, which ended fatally in three days with reds 2,500,- 
000, and leucocytes, 1,000,000 (s. monos., 76.5 per cent.; neutrophilic 
myelocytes, 10.6 per cent.; neutrophile leucocytes, 12.2 per cent.). 

Turk's case is a good illustration of the myelogenous form; red 
cells, 1,060,000; haemoglobin, 19 per cent.; leucocytes, 42,000 (s. 
monos., 14 per cent. ; pmn. n., 32 per cent. ; myelocytes, 47 per cent.). 
The list of blood conditions somewhat similar to the acute myelo- 
genous leukaemia are : an acute exacerbation of a chronic myelogenous 
leukaemia ; a lymphatic leukaemia with an acute infection ; an acute 
lymphatic leukaemia of the large-celled variety (since it is not easy to 
separate these cells from myelocytes) ; an acute infection causing grave 
anaemia, in which case even 14 per cent, of the leucocytes may be 
myelocytes; an acute exacerbation of pernicious anaemia; and finally 
malignant disease of bone-marrow. A large number of nucleated 
reds would suggest this last condition (Billings and Capps). 

Some of these cases may be a sudden acute fatal exacerbation of a 
hitherto unsuspected leukaemia. Wey reported a case of the chronic 
myelogenous form which suddenly became acute, and only then large 
non-granular mononuclears appeared. In others the picture is that of 
an acute infection, and very likely soon such cases will not be consid- 
ered as leukaemia. Clinically it is the anaemia that attracts attention, 
and the relation between these cases and pernicious anaemia is very 
interesting. 

There is no type of cell characteristic of this form ; Frankel's unripe 
cell occurs commonly, but by no means exclusively here ; in 3 of Mc- 
Crae's 5 cases the small lymphocytes predominated. The cells are 
much more uniform than in the chronic forms, yet some are cases with 
large cells, some with medium, and some with small. In some nearly 
all the cells have a basophile protoplasm; in others it is acidophilic 
(Plate II, C). 

The red cells show few changes ; as a rule nucleated reds are scarce, 
yet in Her rick's case they numbered 1800 per cubic millimetre, of 
which some were megaloblasts (but see McCrae's case). The drop in 
count showing rapid blood destruction is a striking feature. 

But in some cases the leucocyte count is not high or even above 
normal ; then for diagnosis the lymphocytes must be always high 
(Klein). Such cases at first resemble pernicious anaemia. 

The cases of acute leukaemia in this clinic have been reported by McCrae. 81 
They numbered five, all of the lymphatic type. Their average duration was six 
weeks, it varying from twelve days to eight weeks. 

On admission, average of haemoglobin, 35.4 per cent.; of reds, 1,822,000; of 



Brit. Med. Jour., February 25, 1905. 



588 



CLINICAL DIAGNOSIS 



leucocytes, 104,000; highest, 326,000 (haemoglobin, 45 per cent.; reds, 3,000,000); 
lowest, 57,800 (reds, 748,000; haemoglobin, 16 per cent.). In one case, in fifteen 
days the reds fell from 3,000,000 to 1,450,000. Color-index is high, 0.93 to 1.4. The 
small mononuclears varied from 94.2 to 99.4 per cent., and in three the small 
lymphocytes were the prevailing cell, unusual in this form of leukaemia. In one 
case occurred many large lymphocytes which were actively motile. Nucleated 
reds were absent in two cases, 2 per 1000 leucocytes were found in three cases 
and in the fifth case 310 per 1000 leucocytes ; i.e., 3720 per cubic millimetre, of 
which 7 per cent, were megaloblasts and 48 per cent, intermediates. McCrae 
emphasizes the high color-index of these and of the cases in literature, and finds that 
of 45 cases in 24 the red count was below 1,500,000, and in 38 of the 45 below 
2,500,000. Of 40 cases from literature, in 20 the color-index was 1 or above, and 
in 20, under 1. The low count and high index of the primary anaemias seem to him 
a special feature of this type of leukaemia. A most remarkable case was recently 
admitted with reds, 752,000; haemoglobin, 17 per cent.; leucocytes, 880,000, large-cell 
type. 

Of 13 cases of acute leukaemia in children, collected by McCrae, 82 the anaemia 
was severe (highest red count, 2,350,000; lowest, 1,000,000), color-index high; 
the red cells were of normal appearance ; no nucleated reds were found in 7 cases, 
few in 4, and megaloblasts in but one. 

The leucocytes varied from 21,000 to 209,000; there was no relation between 
acuteness and character of cells. The absolute number of polymorphonuclears was 
about normal in all cases. In these cases the anaemia is the important feature ; the 
leukaemia would not have been suspected without blood examination. 

Mixed Leukaemia. — These cases may best be described as a lym- 
phatic leukaemia with a considerable number of myelocytes, both 
eosinophile and neutrophile. A few myelocytes may occur in lymphatic 
leukaemia, and the question is one of drawing a line. 

The cause of leukaemia is still to be discovered. A few words, however, may 
be said concerning Lowit's organism. In the splenomyelogenous form he described 




d e 

Fig. 115.— a, b, c, d. four leucocytes containing Lowit's organisms (copied from Lowit) ; <?, large 
granular (and vacuolated ?) cell of bone-marrow. 

Hasmamceba leukaemiae magna ; specific bodies occurring in the large and small 
mononuclears, both non-granular and granular, rarely in the polymorphonuclear 
cells, never in the reds, sometimes free in the plasma. Their size varies much, 
and sometimes all varieties in the same cell. This he considers is due to multiple 
infection, while some of the groups of small cells he considers evidence of multi- 
plication. They are in or on the leucocytes, often in vacuoles or splits of the. 

82 Johns Hopkins Hosp. Bull., May, 1900. 



THE BLOOD : LEUKiEMIA 



589 



protoplasm. They look as if they were amoeboid when they died. They can be 
stained by a particular method, but they differ much in their staining qualities. 
Navicular bodies or crescent bodies are found which first suggested to Lowit the 
parasitic nature of the disease, since they resembled similar bodies in the coccidia 
and the hsemosporidia. 1 hese were never found in other conditions. He 
considers that he can exclude artefacts. He found them in the blood-building 
organs, and states that he got positive results from rabbit inoculation. 

In the lymphatic form he describes Hsemamceba leukaemise parva. This he 
found, however, in but one of five cases studied. They are smaller than the pre- 
ceding, seem more amceboid, are found especially in the blood-building organs, 
very rarely in the peripheral blood, points of resemblance analogous to the sestivo- 
autumnal malaria parasite. Those forms which he considers segmenters have a 
different arrangement and fewer segments. In this form no resting stage was 
found, and he is not certain of navicular bodies. 

These parasites of Lowit have been the subject of a very animated discussion, 
particularly between himself and Turk who considers that they are much altered 
basophile granules or artefacts. The technic to demonstrate them is difficult and 
his findings unsatisfactory. We would expect the protozoa, if such they be, to show, 
as do others of a somewhat similar class, a little more uniformity in size, and a life 
history analogous to theirs. Studying Lowit's plates it would seem difficult 
to bring order out of such a chaos of forms. By unanimous consent the question 
has been allowed to drop, and yet in the blood specimens we have seen stained with 
his method even if all were artefacts they were beautiful pseudoparasites. 

Pseudoleukemia. — Under this heading have been grouped a great 
variety of diseases, including Hodgkin's disease, which now, by re- 
moving a superficial gland, can be easily excluded ; tuberculosis of the 
lymph-glands, which can be recognized by the tuberculin test ; lympho- 
sarcoma and malignant lymphomata, which the pathologists say can 
be recognized anatomically. Others include splenic anaemia. Hence 
scarcely anything is left in the group of pseudoleukemia, and it is the 
opinion of some that a " true" pseudoleukemia is still to be proved 
(Reed) ; that is, a disease with the anatomical features of leukaemia, 
but not its blood-changes. 

By the term pseudoleukemia is generally meant a condition the 
clinical picture of which (the swollen lymph-glands and the cachexia) 
is that of lymphatic leukemia, but without its blood-changes, and such 
cases are common enough, as the above list shows. Some cases which 
could be brought under this head are certainly early stages of lymphatic 
leukemia, or cases during aleukemic periods, yet other cases are 
chronic, even for eight or ten years. 

Hodgkin's Disease. — The blood features of this disease are those 
of cachexia. In the eight cases reported by Reed the red count varied 
from 3,232,000 to 5,264,000 on admission. One case was as low as 
2,670,000, but afterwards improved. These cases were, therefore, 
somewhat anemic, and two showed a severe anemia of the secondary 
type. At the onset the count may be practically normal and for months 
remain so despite the rapid growth of the lymph-glands. Then begin 
the changes of an ordinary secondary anemia, often extreme, with at 
the end a count as low as 1,522,000, with degeneration of the red cells, 



590 



CLINICAL DIAGNOSIS 



nucleated reds, and poikilocytes which are noticeably rare except at 
the late stages. The leucocytes are slightly increased, averaging about 
12,000. In two of the eight cases there was an absolute increase of 
small mononuclears, but the lymphocytosis of Pinkus is by no means 
constant. The maximum count of small mononuclears was 38.6 per 
cent., the absolute, therefore, 5304, and the next highest was 4600 
(36.8 per cent.). In two cases the small mononuclears were low, in 
one 2 per cent., or 310 cells, in another 9.4 per cent., or 940 cells. 
Grawitz considers that while the differential count is no aid in diag- 
nosis, it is for prognosis : that a slight increase accompanies improve- 
ment, and a decrease, the reverse. 

Tuberculosis of the Lymph-Glands. — In some cases of general 
glandular tuberculosis there is a normal red and leucocyte count, in 
other cases cachexia with a secondary anaemia. Some very interest- 
ing cases have a very low leucocyte count. In one case it was only 
300 cells per cubic millimetre (Futcher). Most consider the blood of 
little value in the diagnosis of this condition. 

Of this disease we have recently had 12 cases. Four of these showed a leuco- 
cytosis of from 11.000 to 29.000. The red cells were slightly decreased (two cases, 
3,600.000 and 3,700,000, and 6 cases from 4,000,000 to 5,000,000), the haemoglobin 
was much reduced and in 6 cases the index below 0.6. As a rule, there is no 
leucocytosis until a secondary infection occurs. 

A case like the following is a puzzle for diagnosis. The woman, aged fifty 
years, had a red count of 4,000,000 ; haemoglobin, 50 per cent. ; leucocytes, 8000. 
She had tuberculosis of the lungs, also swollen lymph-glands, two of which were 
removed with an interval of one year, and both pronounced tuberculous. She had 
night-sweats and lost weight. Three months after the above blood-count the glands 
began to swell enormously : red cells, 3,000,000 ; leucocytes, 80,000, 96 per cent, 
of which were polymorphonuclear neutrophiles. A little later the count had 
risen to 120.000 ; lymph-glands and spleen enormous. She received X-ray treat- 
ment, and in three weeks the leucocytes were 16,000 and the reds 2,100,000. She 
died soon after. 

Leukanaemia is the name given by v. Leube to a group of cases 
formerly grouped by some with the acute leukaemias, and by others 
with the pernicious anaemias ; the features of both are present. Rather 
than as an independent blood disease it is considered 83 a symptom of 
a large number of conditions, — injuries, hemorrhage, intoxications, 
infections, malaria, malignant growths, etc. There is severe anaemia 
with nucleated reds of all varieties, and a normal or increased white 
count, with many myelocytes, but no eosinophiles. Other cases 
resemble lymphatic leukaemia. 

The anaemia usually precedes the increase in white cells. 

BLOOD IN ACUTE DISEASES 

Malaria. — The anaemia of malaria is important in diagnosis, since it 
is one of the earliest symptoms, the count dropping from 5,000,000 to 

83 Luce, Deut. Archiv. f. klin. Med., 1900, vol. lxxvii. p. 215. 



THE BLOOD: ACUTE DISEASES 



591 



even 500,000 in a few days. It is due both to the direct destruction of 
the corpuscles by the intracellular parasites and to the destruction of 
red blood-cells not containing parasites, the latter seen especially in 
those cases with hemoglobinuria, in which the haemolysis is serious. 

The red blood-cells decrease after each paroxysm, slightly in the 
tertian and the quartan malaria, more in the aestivo-autumnal in which 
case there may be a drop of 1,000,000 cells after one paroxysm. 

In 54 cases of aestivo-autumnal malaria the red cells were between 1,000,000 
and 2,000,000 in two cases, 2,000,000 and 3,000,000 in 12, 3,000,000 and 4,000,000 
in 20, and 4,000,000 and 5,000,000 in 12, above 5,000,000 in 8. In 56 cases of tertian 
the figures for these same limits were 1, 10, 28, 13, and 4 respectively. It is seen 
that in our cases these two forms differ little. The mean count for each was 
3,500,000. But in this climate we seldom see truly pernicious cases. 

In the " pernicious" cases the count drops somewhat also between 
the paroxysms. In Grassi's case there was a loss of 4,000,000 cells 
in six days. In one case the count at the end of thirty days was 500,- 
000. Dionisi reports a case in which each chill cost from a half to one 
million red blood-cells. The greatest fall is in the earliest paroxysms, 
later less, until finally the count remains almost stationary despite 
repeated paroxysms. In cases with pernicious malaria and haemo- 
globinaemia the anaemia is grave, with poikilocytes, endoglobular de- 
generations, occasional shadows, fairly numerous nucleated reds, in- 
creased platelets, and leucocytosis. 

The regeneration of the cells in the tertian and quartan is rapid, 
the count often being restored before the next paroxysm, and anaemia 
occurring only after a long series of chills. In the aestivo-autumnal the 
recovery is slower, the new cells pale, varying in size and shape; nu- 
cleated reds are common, and since the anaemia is chronic the regenera- 
tion is slow, and grave anaemia may result. This slowness in regenera- 
tion is due also to the extensive necrosis and the resulting fibroid 
induration of the bone-marrow, which may be the chief seat of the 
infection, and to the accumulation of pigment in this tissue. The 
haemoglobin suffers even more than the red blood-cells and returns to 
normal more slowly. 

The leucocytes are almost always subnormal in malaria, an im- 
portant point in diagnosis, except in the grave pernicious paroxysms. 
They rise slightly (to 6700, some say to a true leucocytosis) just 
before the paroxysm, and then steadily fall, reaching a minimum 
(average 2300) at the time the temperature is subnormal, and some- 
times to as low as 1000 to 2000 cells. 

In 82 recent cases of aestivo-autumnal malaria the leucocyte counts were, from 
1000 to 2000, 3; 2000 to 5000, 8; 3000 to 4000, 21 ; 4000 to 5000, 15; 5000 to 6000, 
14 ; 6000 to 7000, 8 ; 7000 to 8000, 4 ; 8000 to 9000, 2 ; 9000 to 10,000, 2 ; above 
10,000, 5, one of these a pernicious case (14,500) ; mean 3500. 



592 



CLINICAL DIAGNOSIS 



In 70 cases of tertian malaria the figures for these same limits were 2, 5, II, 
18, 10, 10, 5, 2, and 2; above 10,000, 5; highest, 16,500; mean, 4500. 

The differential count shows a relative decrease of the polymor- 
phonuclear neutrophiles, and an absolute increase of the large mononu- 
clears. The mean averages found by Thayer are : Small mononu- 
clears, 16.9; large mononuclears, 16.9; polymorphonuclear neutro- 
philes, 65 ; eosinophils, 0.9 per cent. ; in grave cases, myelocytes 2 to 3 
per cent. (Cabot). The increase of the large mononuclears, very pro- 
nounced in the apyretic periods, is usually absent in the pyretic periods. 
If as the temperature falls these cells do not increase, it is evidence 
against malaria, while they are most valuable in the diagnosis of cases 
admitted after they have taken quinine, and hence without parasites in 
the peripheral blood. In the tropics Stevens and Christophers say that 
over 15 per cent, large mononuclears means an actual or a recent 
malaria ; with 20 per cent, one almost always finds the parasite. This 
increase affects the cells which Uskow calls " transparents," a group of 
cells which vary in size from lymphocytes to the largest cells of the 
blood, which are slightly amoeboid and distinctly phagocytic, in fact, 
the chief phagocytes in malaria, sometimes containing a few pigment 
granules, sometimes many, these pigmented cells being almost as im- 
portant in diagnosis as is the parasite itself. 

The}- occur much of the time in the aestivo-autumnal form but only after the 
paroxysm in tertian and quartan. These phagocytic cells are said to rapidly become 
necrotic and to disappear from the circulation, which explains the diminution in the 
count at the end of an attack. 

Stephens and Christophers cite, as illustrations of this relation of 
the leucocytes, the following cases : Bastianelli's fatal comatose case of 
aestivo-autumnal malaria, in which the small mononuclears were 19.1 
per cent., the large mononuclears and transitionals, 41 per cent. ; poly- 
morphonuclear neutrophiles, 39 per cent., and eosinophile cells, 0.6 per 
cent. Panse's case, with a temperature at 37.2 0 C, and the small 
mononuclears, 18.1 per cent.; large mononuclears and transitionals, 
26.4; polymorphonuclear neutrophiles, 55.3. In another case with 
temperature normal the small mononuclears were 14.8 per cent. ; large 
mononuclears and transitionals, 46.7 per cent. ; neutrophiles, 38.5 per 
cent. 

In one of our tertian cases the total leucocytes were 16,500 ; large mononu- 
clears, 38.3 per cent. ; in a case of aestivo-autumnal, leucocytes, 6000, large mono- 
nuclears, 26 per cent. ; in another, 4000 and 22 per cent. 

A leucocytosis occurs rarely except in pernicious paroxysms. In 
one case in this clinic the count one hour before death was 50,000, of 
which the large mononuclears and transitionals were 18 per cent., the 



* 



THE BLOOD: ACUTE DISEASES 593 

polymorphonuclear neutrophiles, 58 per cent. It occurs also in malarial 
haemoglobinaemia, in which case there is a marked increase in the poly- 
morphonuclear neutrophiles, which begins with the attack and lasts for 
some time. A leucocytosis is seen also during the death agony, and is 
due to complications. There is a definite leucocytosis in the post- 
malarial anaemia, sometimes with increased eosinophiles and with 
myelocytes. 

Bignami and Dionisi classify the anaemias of malaria as follows : Those which 
follow ordinary acute malarial fever, in which there is a secondary anaemia of a 
chlorotic type, without leucocytosis, with a few nucleated reds, leucocytes reduced, 
the large mononuclears relatively increased; (2) cases resembling primary perni- 
cious anaemia, usually fatal, with extreme oligocythaemia, marked poikilocytosis, 
high color-index, nucleated reds if present for the most part megaloblasts, leuco- 
cytes diminished, and lymphocytes relatively increased; (3) rapidly fatal cases 
without any signs of regeneration which may have been in the first stages those of 
simple secondary anaemia. This anaemia is very similar to that which follows a 
severe hemorrhage. 

(4) Chronic grave secondary anaemias of a chlorotic type and without nu- 
cleated reds ; leucocytes much reduced. This is seen in a chronic malarial cachexia, 
and is due for the most part to degenerative changes in bone-marrow occurring 
after long infections, with the marrow sclerotic and pigmented (Thayer). 

Septicaemia. — That septicaemia does not always cause a leucocytosis 
is seen in typhoid fever and acute miliary tuberculosis, and yet as a 
rule it does, but less constantly and markedly than do local pus 
accumulations. In the streptococcus and staphylococcus septicaemias, 
however, there is often a marked anaemia, with a greater and earlier 
fall than in any other acute disease. In one case of acute streptococcus 
septicaemia with hemorrhages (Grawitz) the cells fell to 300,000 in 
twenty-four hours. Septic fevers as a rule cause a loss of from 
200,000 to 1,000,000 cells per week; that of puerperal infection has 
an especially bad effect upon the reds. The qualitative changes are 
marked, — degeneration, poikilocytosis, polychromatophilia, etc. ; nu- 
cleated reds occur seldom in large numbers. The leucocytes vary as 
the patient's resistance, in some cases being very high, in other cases 
even subnormal. 

We have had 26 cases of well-marked septicaemia. The final red counts in 
15 fatal cases were from 1,000,000 to 2,000,000 in 2; 2,000,000 to 3,000,000 in 3; 
3,000,000 to 4,000,000 in 4 ; above 4,000,000 in 6. 

It is thus seen that the toxine does not kill through the anaemia (the drop in 
count after admission and before death was from 900,000 to 1,600,000), and that 
there are two groups of cases, those with high and those with low counts. 

In 4 cases there was no leucocytosis at death. In 21 cases the leucocytes varied 
from 11,000 to 47,000. Some cases showed great variations in the white count. 
In one case with 8000 leucocytes 96.6 per cent, were polymorphonuclears ; in another, 
of 10,400, 92.6 per cent. Gonorrheal septicaemia caused a drop to 2,318,000, with 
30 per cent, haemoglobin, and at death leucocytes, 47.000. 

Chronic septicemia it is important to diagnose, those cases of 
cryptic origin often passing unrecognized. In Ewing's case of em- 
38 



594 



CLINICAL DIAGNOSIS 



pyemia, with a duration of one year, the red blood-cells were 1,800,000, 
and the haemoglobin 25 per cent. In other cases of pelvic abscess of 
even two years' duration the anaemia is slight. 

We have had recently four cases of Typhus Fever: 

Case I. — Male, thirty-six years; red cells, 5,400,000; haemoglobin, 
72 per cent.; leucocytes on admission, 18,600; temperature, 103 to 
104 0 F. On the eighth day after admission, 25,400; the temperature 
had begun to fall. Five days later, temperature normal ; total count, 
24,300; s. m., 3.2 per cent.; 1. m. and tr., 6.6 per cent.; pmn. n., 90 
per cent. ; eosinoph., 0.2 per cent. 

Case II. — Male, nineteen years; red cells, 4,500,000; haemoglobin, 
70 per cent. ; leucocytes on admission, 8600, and remained normal for 
four days; temperature, 102 0 to 105 0 F. On the fifth day, count 
12,500; on the tenth day, with temperature normal, total, 10,000; 
s. m., 6 per cent. ; 1. m. and tr., 4.2 per cent. ; pmn. n., 89.4 per cent. ; 
eosinoph., 0.2 per cent. 

Case III. — Male, thirty years; red cells, 5,500,000; haemoglobin, 
85 per cent. ; leucocytes on admission, 7000, and remained normal 
three days; temperature, 101 0 to 103 0 F. On the fifth day, 38,000; 
temperature, 98 0 F. ; death (total count, 38,000; s. m., 5.8 per cent.; 1. 
m. and tr., 1.2 per cent.; pmn. n., 93 per cent.). 

Case IV. — Male, twenty-two years; red cells, 5,400,000; haemo- 
globin, 85 per cent. ; leucocytes on admission, 9200, and normal three 
days; temperature, 102 0 to 104 0 F. On the tenth day they had risen 
to 11,600, but the temperature had already been normal three days. 
Leucocytes normal on the twelfth day (total, ninth day, 10,800; s. m., 
15 per cent.; 1. m. and tr., 1 1.5 per cent.; pmn. n., 72 per cent.; 
eosinophiles, 1.0; Matzellen, 0.8 per cent.). 

From these four cases (daily counts were made in all) it is seen that 
the leucocytes are low on admission, even normal, then rise to a maxi- 
mum, which occurs when the temperature has begun to fall or is 
already normal, then they fall to normal. (Compare with influenza 
and variola.) 

This is different from the findings of Ewing and Thomas, who 
report absence of leucocytosis. 

Measles and German measles have almost no influence on the red 
blood-cells, and cause no leucocytosis, or only a slight one. In the 
post-febrile stage the large mononuclears are increased. 

Plantenga found in the thirteen cases of measles and the nine of Rotheln which 
he studied, a neurophile hyperleucocytosis of even 20,000 during the prodromal 
stage, which rapidly gave place to a hypoleucocytosis during the eruptive stage, 
due to the disappearance of the neutrophile cells, and with sometimes a lymphocy- 
tosis and the disappearance of eosinophiles. 

Renaud found in six cases that this preliminary leucocytosis reached its maxi- 



THE BLOOD: ACUTE DISEASES 



595 



mum about six days before the rash had appeared. This leucocytosis permits one 
to isolate a suspected case early. 

Tileston could not confirm this leucocytosis during the prodromal stage, and 
thought all leucocytoses could be attributed to a complication. 

We have very little material, but in nine recent cases in only one was the count 
above 8600 during the height of the fever (17,200). 

Scarlet fever has very little effect upon the red blood-cells, but does 
cause a slight anaemia, the count averaging 4,500,000 (Reckzeh). 
The leucocytes are uniformly increased, an important point in diag- 
nosis, rising during the incubation period, in some cases six days be- 
fore the rash, and continuing elevated into convalescence and even 
until twelve days after the temperature has reached normal. This is 
an interesting- exception to the rule of other diseases that the count 
runs roughly parallel to the temperature. They are generally normal 
on the fourteenth day (Reckzeh). The leucocytes vary from about 
10,000 to 40,000; mild cases, 10,000 to 20,000; moderate, 20,000 to 
30,000; severe, 30,000 to 40,000, according to the severity of the case 
and its duration. The neutrophile cells are relatively increased (to 
85 to 98 per cent, especially in fatal cases) ; the eosinophil cells 
rapidly disappear and reappear with improvement ; their failure to reap- 
pear is considered a bad sign. As a rule the eosinophiles reach their 
maximum two or three days after the rash appears, and are normal 
after the leucocytosis has disappeared. This early presence of eosino- 
philia is important in the diagnosis, excluding various septic conditions. 

Diphtheria. — In this disease there is a moderate anaemia, a loss of 
about two million cells at the time of defervescence. During the 
height of the disease, however, there is often an increase in the count 
and specific gravity. (The injection of bacilli or their toxines into the 
circulation of animals causes a lymphagogue action which results in a 
hypercythaemia. ) This hypercythaemia occurs most commonly in this 
of all the acute infections. In the case of Cutter the cells were from 
7,200,000 to 7,800,000; in that of Morse from 5,000,000 to 5,500,000 
during the first week, and 6,800,000 during the second. With the 
drop in the count the nucleated reds and the polychromatophilic cells 
appear. There is a slight leucocytosis — as a rule, 10,000 to 15,000, 
but in severe cases even 17,000, and with complications 30,000 — which 
varies as the severity of the infection. The rise is in the polymorpho- 
nuclear cells. In some fatal cases there is leucopenia. The myelocytes 
are increased, especially in the fatal cases, to from 3 to 16 per cent. 
Morse says : " The examination of the blood in diphtheria is of no 
practical clinical importance in diagnosis, prognosis, or treatment." 

In ordinary follicular tonsillitis the counts are often as high as in 
diphtheria. 

Smallpox. — " No other disease is so destructive to the red blood- 
cells " (Hayem). The anaemia is evident as the temperature falls, and 



596 



CLINICAL DIAGNOSIS 



the question often arises whether it is truly due to a destruction of cells 
or merely to a dilution of the blood from the relaxed vasomotor tone. 
Yet during the pustular stage especially there may be a loss of 2,000,- 
000 cells. Regeneration is slow, lasting about fourteen days. In the 
hemorrhagic form the anaemia is severe and varies with the amount 
of hemorrhage. Pick and Weil say that there is anaemia in the severe, 
none in the mild cases. Malassey says that the drop begins in the pust- 
ular stage, and that the rise begins with the desiccation or even during 
convalescence. The nucleated reds (normoblasts) are rare, except in 
the hemorrhagic form, in which they may be very numerous. 

Leucocytes. — From the onset with a normal count the blood for- 
mula is very characteristic of this disease. The polymorphonuclear 
neutrophiles are decreased, averaging about 40 per cent, or even 20 or 
14 per cent. ; the small mononuclears vary from 30 to 40 per cent. ; 
the large mononuclears from 4 to 10 per cent.; myelocytes and irrita- 
tion forms each 2 to 10 per cent. 

The disease per se causes no leucocytosis, but during the pustular 
stage the leucocytosis is said to be the result of the infection by the 
skin cocci. 

Tuberculosis. — Tuberculosis is a disease the virus of which can cause 
anaemia of the highest grade {e.g., v. Limbeck's case of tuberculosis of 
the peritoneum and other abdominal organs, with a red blood-count of 
730,000 and haemoglobin 25 per cent. ; such cases are so rare that this 
one is doubted by Cabot), but usually one of moderate grade, one often 
more apparent than real, and which may not exist at all. The degree 
of the anaemia is independent of the localization of the disease. 

In tuberculosis in general a mild grade of chlorotic anaemia is 
the rule. This occurs in slight involvement of the apex (" anaemia of 
onset ") without fever, in tuberculosis of bones and lymph-glands. 
This is the " pseudochlorosis tuberculosa." The count is almost nor- 
mal, the leucocytes normal, and the haemoglobin somewhat reduced. 
In other cases there is a lymphocytosis, absolute or relative ; in some 
few cases a reduction of the count as well as of the haemoglobin. 
Qualitatively some of the red blood-cells (not the majority, as in 
chlorosis) are rather pale and small; poikilocytes are usuallv few, may 
be numerous, but are rarer than in other cachexias of the same degree; 
nucleated reds are rare, even after a severe hemorrhage and when the 
anaemia is extreme, a point of importance in the differential diagnosis 
between this and carcinoma ; Maragliano's eridoglobular degeneration 
is seen in severe cases, especially in those of mixed infections. 

Cabot considers that the tuberculous virus has itself but little effect on the 
blood, and that the above-mentioned changes are due to secondary infections, or 
to drains upon the proteid of the blood from diarrhoea, effusions, starvation, pro- 
longed suppuration, etc. 



THE BLOOD: TUBEECULOSIS 



597 



In a pure case, with the exception perhaps of meningitis, the leuco- 
cytes are not affected. This is important in the diagnosis of peritonitis, 
bone troubles, and acute miliary tuberculosis. Qualitatively in some 
cases there is no change, and yet in others with a normal count is seen 
the increased percentage of the mononuclear cells common in all condi- 
tions with poor nutrition. If there is a leucocytosis, it is of the ordinary 
inflammatory type. The eosinophile cells are increased in some cases 
with cavity formations, and since this occurs also after the injection of 
tuberculin some think it is due to an autointoxication from the cavity. 
Myelocytes appear in advanced cases. 

Chronic Tuberculosis of the Lung. — Grawitz has divided 
these cases into three groups: Group I, with slight involvement of the 
apex, without fever, showing clear signs of anaemia, the pseudochloro- 
sis tuberculosa, some with a normal count, others with a slight reduc- 
tion, the leucocytes normal. Some early cases have almost normal 
blood. Whether there is a group in which the blood signs precede the 
physical signs may depend on the care with which the physical signs 
are sought. Group 2, cases of chronic phthisis with cavity formation 
but without other complications, the temperature slight; the blood 
picture is remarkably normal as regards count, haemoglobin, specific 
gravity, dry constituents, yet there is with the cavity formation a gen- 
eral emaciation. Such a patient earlier had a distinct chlorosis ; the 
leucocytes are normal or slightly increased, from 10,000 to- 15,000 per 
cubic millimetre. Group 3, of cases with hectic fever, supposed by 
some to be due to a secondary infection but by others to pure infection 
with the tubercle bacillus. In these cases there is a true anaemia, a 
diminution in the count, sometimes rapid, of the haemoglobin and dried 
substances, an anaemia which progresses often until death, with evi- 
dence of true blood destruction. The drop in the count may even be 
rapid. 

In a recent case of pulmonary tuberculosis, two days before death the red 
cells were 1,473,000; haemoglobin, 15 per cent.; leucocytes, 9000 (pmn. n., 88 
per cent. ; s. m. 5.9 per cent. ; 1. m. and tr., 4.7 per cent. ; eos., 0.35 per cent. ; normo- 
blasts, 4, megaloblasts, 4 per 1000 leucocytes) 

There is leucocytosis as a rule, especially if there is a secondary 
infection. In fact, v. Limbeck considers the presence of a leucocy- 
tosis sufficient guarantee of a secondary infection. Others disagree, 
for in the chronic septicaemic form there is a slight leucocytosis, and 
in caseous pneumonia as high a leucocytosis as in croupous pneumonia.. 

The normal count in the second stage has aroused considerable discussion. A. 
concentration of blood by sweating, diarrhoea, and vomiting is not alone sufficient,, 
although, if present, will help. Some consider the hypercythsemia a compensatory 
feature for the dyspnoea, since dyspnoea due to any cause produces a hypercythsemia ; 



598 



CLINICAL DIAGNOSIS 



others admit an anaemia which is covered by an oligemia, and autopsies at this stage 
suggest a diminution of the total volume of blood. V. Limbeck considers the 
changed water metabolism the important point, the general drying of the tissues 
concentrating the blood ; i.e., an oligemia vera. Grawitz considers the absorbed 
products of caseous nodules to have a lymphagogue effect, thus concentrating the 
blood. 

After haemoptysis the regeneration may be rapid (see page 551) ; 
after operation on a tuberculous focus if the haemoglobin does not 
return rapidly the operation was probably incomplete; in some cases 
the anaemia accompanies the dissemination of the bacilli ; in others the 
count rises and one can find no parallelism between the general condi- 
tion of the patient and his blood ; in fibroid phthisis, as a rule, there is 
no leucocytosis ; in acute phthisis the anaemia is pronounced and pro- 
gressive. In cases of cavity formation there is almost always a leuco- 
cytosis. In extensive tuberculous pneumonia some have little, others 
as high a leucocytosis as in croupous pneumonia. Acute miliary tuber- 
culosis presents no change in the red blood-cells or haemoglobin, and 
the leucocytes usually remain normal, but in a few cases are very low, 
even from 500 to 600 cells, over 90 per cent, of which are polymor- 
phonuclear neutrophiles. 

Tuberculosis of the serous membranes is accompanied by a mild 
secondary anaemia without leucocytosis unless the blood be concen- 
trated by diarrhoea, except, perhaps, in some cases of meningitis, which 
is accompanied by a leucocytosis (Osier). In tuberculosis of the 
glands there is no leucocytosis until caseation begins. The injection of 
tuberculin into a tuberculous patient causes a leucocytosis with a rise 
of eosinophiles. In tuberculosis of the bones there is a marked absence 
of leucocytosis until a secondary infection sets in ; a high count indi- 
cates abscess formation, but after the abscess has become chronic the 
count may remain normal until a secondary infection occurs. In these 
bone cases the reds are rarely diminished, but the haemoglobin is low. 

The very slight anaemia found in children is rather remarkable, 
since their blood is usually so susceptible. Brown, 84 in 73 cases, found 
the red blood-cells diminished only in the long-standing extensive cases 
in very young persons, but the haemoglobin was diminished somewhat 
in all. 

Of 17 cases of acute miliary tuberculosis, in 5 cases the red cells stood 
between 3,600,000 and 4,000,000, and in 6 over 5,000.000. The color-index was quite 
low, in one-half the cases from 0.4 to 0.6. The leucocytes varied from 1000 to 
9000, the majority (9) from 3000 to 6000. 

One case had an interesting differential count (total, 3500; s. m., 6.5 per cent; 
1. m. and tr., 10.8 per cent.; pmn. n., 81.9 per cent.; eosinophiles, 0.5 per cent). 
Whartin's case with lower count, had 91.48 per cent. pmn. n. 

Whartin reported a case with leucocytes often below 2000, and on one day 
(with a chill) 600, and Cabot a case with 550. 

84 Trans. Med. Soc. of the State of California, 1897, p. 168. 



THE BLOOD: TUBEECULOSIS 



599 



Tuberculous meningitis is an illustration of the general rule that the effect 
of an infection upon the leucocyte count depends partly on the location of the 
lesion, for tuberculosis of the meninges usually causes a leucocytosis. 

Of 15 cases, in only 3 was the count below 10,000, and one of these was only a 
part of an acute general miliary infection. In the other two, one count each was 
made. The leucocyte curve is a very irregular one, 3 of our cases with high counts 
showing periods with low counts. 

The highest count was 26,800. 

In the series of 43 cases reported by Cabot there was leucocytosis in 32. 

Tuberculous Peritonitis. — During the past four years we have had 22 cases. 
Of 19 cases in which the red cells were counted, 7 were between 3,000,000 and 
4,000,000, and 6 between 4,000,000 and 5,000,000. The color-index varied from 0.5 
to 1. Of the 22 cases there was a leucocytosis in 9 (highest count, 22,400). 

Of Cabot's 60 cases there was a leucocytosis in 14. 

Tuberculosis of Bones and Joints. — These cases are reported chiefly from sur- 
gical clinics. There have recently been 15 cases in this clinic, with a leucocytosis in 6. 

It is believed that during the active process of abscess formation there is a 
leucocytosis which in time will disappear, to reappear in greater degree if a sec- 
ondary infection occurs; hence the high jump in the count which is a measure of 
the sepsis following operation, as a rule, this leucocytosis will soon subside, and 
so long as the abscess drains freely either not appear or the count will remain 
fairly low. 

Tuberculosis of the Intestine. — Of 5 cases there was a sec- 
ondary anaemia in 2 (3,300,000 and 2,800,000 red cells). In one a 
leucocytosis of 14,000, which disappeared soon after admission. 

Two cases of renal tuberculosis showed no leucocytosis. 

One case of Addison's disease had red cells, 6,600,000; haemo- 
globin, 92 per cent. ; leucocytes, 9000. Sometimes there is marked 
anaemia in this disease. 

Typhoid . Fever. Red Blood-Cells. — In the fresh blood smear may 
sometimes be found the very large phagocytic cells crowded with red 
blood-cells which Mallory has emphasized. Some find a slight rise 
of reds during the first week, then a slow fall to normal, and at the 
time of defervescence a true drop. Thayer 85 has reported the cases 
of this clinic. He found that from the end of the first week until 
defervescence there was a gradual reduction in the number of red 
cells, and that with defervescence regeneration began. In very long- 
continued cases the regeneration may begin slightly before the tem- 
perature is normal. The loss of reds averages 1,000,000 cells. The 
end of the third week is the average limit of the disease, at which 
time the average count of our cases was 4,555,814. The fall may be 
accentuated during the fourth week, and, indeed, the usual statement 
is that the anaemia begins at this time. During this period there are 
transitory variations in the count due to vomiting, sweating, diarrhoea, 
etc. Following a severe hemorrhage the anaemia is manifest, and 
regeneration begins at once. 

Following some very severe cases is a post-typhoid anaemia, in 
one case with 1,426,000 red cells during the fourth week; in another 



Johns Hopkins Hosp. Rep., vol. viii. 



600 



CLINICAL DIAGNOSIS 



case 1,300,000 during the third week (both Osier's cases), and one 
case of 804,000 (Henry). Usually there are no qualitative changes. 
After a hemorrhage are sometimes seen nucleated reds. 

There is always a more marked reduction in the H/Emoglobin than 
in the reds, the color-index, according to Thayer, varying from 0.7 to 
0.8. In the above case with 1,300,000 cells the haemoglobin was 20 
per cent. The haemoglobin runs parallel to the red blood-cells, but 
returns to normal more slowly. 

The leucocytes, some think, are slightly increased at the very first, 
but apart from this they are subnormal during the whole course, and 
gradually diminish from the first (with 6400) to the fifth week, at 
which time the average of our cases was 5386. Some cases reach 2000, 
1000 per cubic millimetre, or even lower. Thayer found no cases with 
an initial leucocytosis. The longer and more intense the infection the 
lower the leucocytes. In still other cases the count is above 10,000 
throughout the whole course, cases without any complication. There 
may be temporary variations, the count rising to 10,000 cells after a 
cold bath, e.g., yet with the differential count unchanged. 

The differential count for the first five weeks shows a decrease in 
the percentage of polymorphonuclear neutrophiles, usually to 60 per 
cent., and below 50 per cent, not rarely, and an increase of the mono- 
nuclears, especially the large, the transparent cells of Uskow, cells 
which are morphologically not lymphocytes, but which vary in size 
from these to the largest cells of the blood. They have relatively 
abundant protoplasm and faintly staining nuclei. These are especially 
numerous at the height of the fever. The eosinophile cells are reduced 
below 1 per cent., as a rule, until convalescence, when they increase to 
even above normal. They may, however, in long continued cases, 
increase with the increase in reds before the temperature is normal. 
During convalescence the count returns slowly to normal, but the blood 
retains its characteristic features for about three weeks after the tem- 
perature is normal. 

The blood picture is modified by various complications. Hemor- 
rhage causes an acute post-hemorrhagic anaemia with leucocytosis, the 
lowest count of our series being 1,992,000 cells; regeneration begins 
at once, and the cells are usually restored in a little over one week. 

The inflammatory complications are accompanied by a rise, or even 
a true leucocytosis. This is true of furunculosis, phlebitis, thrombosis, 
bronchitis, periostitis, pleurisy, pneumonia, etc. A definite rise in the 
count, already very much reduced, is for that person often a true leuco- 
cytosis; for instance, in one case in our wards the leucocyte count 
accompanying parotitis rose from 1600 to 3200 cells, comparable to a 
rise in a normal person to about 15,000 cells. 

In one case of empyema the count was 44,500; in a second case, due 



THE BLOOD: PNEUMONIA 



601 



to the typhoid bacillus, 23,000 cells, of which 68.5 per cent, were poly- 
morphonuclear neutrophiles ; small mononuclears, 12.7 per cent., and 
large mononuclears, 17 per cent. 

Of the 5 cases of pneumonia of our series, 3 cases, of whom 2 died, 
had counts above 10,000 cells; 2 cases, both of whom died, below 
10,000 cells. In all of these cases the differential count showed a 
smaller percentage of the polymorphonuclear neutrophiles than one 
would expect. In periostitis due to the typhoid bacillus the leucocytes 
in one case were 18,000, of which 72.5 per cent, were polymorphonu- 
clear neutrophiles. Thayer cites many similar illustrations showing 
that in an inflammation clue to the typhoid bacillus the reaction of the 
blood depends more upon the situation of the infection than upon the 
organism, and the tendency, as illustrated by the above cases of em- 
pyema and periostitis, is for the formula of typhoid fever to persist. 

Perforation. — In our cases of suspected intestinal perforation the 
leucocytes are followed with the greatest care, and interpreted as 
in appendicitis. From the onset of the first symptom, whether it be 
abdominal pain, hiccough, or any other feature which points to the 
abdomen, the leucocytes are counted each hour. If the abdominal 
features are suggestive of perforation, the operation is performed, 
whatever the leucocytes may show. If, however, there is a rising count, 
an operation is performed although the local signs may seem insuffi- 
cient. It is granted that a rising leucocytosis may mean something 
else than perforation. In one of our cases it was appendicitis. In 
this clinic practically every case in which either of these features is 
present is operated upon, under the belief that it is much safer to 
operate too soon than too late, and that an unnecessary operation 
affects very slightly the course of the typhoid fever. We have suc- 
ceeded in this way in saving about 30 per cent, of our cases of perfora- 
tion. In most cases there is a slight rise of the leucocytes, either am 
absolute leucocytosis of 10,000 or over, or one relative to the previous 
counts. Following this rise is sometimes a drop which some suppose 
is coincident with the spread of the peritonitis. In some malignant 
cases occurs a fall without any preliminary rise. In those so-called pre- 
perforative cases there is a slight leucocytosis due to the local perito- 
nitis. While a great deal of weight is placed upon the leucocyte count 
no absolute value is allowed it, and it is always interpreted in the light 
of the physical examination. 

Pneumonia. — The coagulation is rapid, as a rule. The count of the 
red blood-cells is normal during the fever, or there is a rise at first, as in 
Sadtler's case to 7,000,000. After the crisis there is always a drop of 
about 500,000 cells, sometimes a slight post-febrile anaemia. The 
hypercythsemia is probably due to the concentration of the blood. This 
often covers a real anaemia caused by the loss of blood to the exudate 



602 



CLINICAL DIAGNOSIS 



and by the destruction of the blood-cells, as shown by the jaundice and 
the urobilinuria. Cases with these two features show a greater anaemia 
than others, with a loss of about 2,000,000 cells. The drop which 
occurs on the day of crisis is partly the disappearance of the hypercy- 
thsemia and a drop below normal due to the general peripheral relaxa- 
tion (Grawitz). In addition to this is a certain grade of true anaemia 
which sometimes is severe. 

Nucleated reds are more common in pneumonia than in other acute 
fevers. Both normoblasts and megaloblasts occur, which latter have 
a bad prognostic import only when present in considerable number. At 
the time of the crisis it is thought the cells crenate more easily than 
normal, evidence of some chemical irritant in the blood. 

In 34 cases in which special attention was paid to the red blood-cells there 
occurred a drop during the lysis or just after the crisis, generally of about 1,000,000, 
but in some cases of 2,000,000 cells, which drop usually only restored the count 
to that level which obtained before the hypercythaemia. The later counts showed 
small gains and losses in an even number of cases and of about the same degree, 
but in 9 cases there was a permanent loss of from 900,000 to 1,500,000, and in 4 
cases a gain of from 700,000 to 1,900,000. 

Pneumonia is the disease in which the inflammatory leukocytosis 
has been best studied. None of our cases showed evidence of an initial 
hypoleucocytosis, as claimed by Pick. From the first, six to eight hours 
after the chill, the leucocytes are found increased, and they drop at about 
the time of the crisis. This leucocytosis is an expression of the resist- 
ance of the organism to the infection, and depends but little on the fever 
and the extent of consolidation. Cabot has divided the cases into three 
groups : ( 1 ) Those with good resistance and a mild infection, in which 
there may be no leucocytosis ; these cases all recover. (2) Those with 
a severe infection and a good resistance, in which the leucocytosis is 
high, between 20,000 and 30,000, but in some cases over 100,000, 
even 115,000 (Lohr). This group includes about 90 per cent, of all 
cases. (3) Those cases with a poor resistance but a severe infection, 
in which there is no leucocytosis or even a fall, and which cases are 
almost always fatal. The best illustrations of this last group are the 
terminal pneumonias of chronic diseases, pneumonia in the aged and in 
alcoholics. In fatal cases in which the count does not rise the percent- 
age of polymorphonuclears may rise considerably. In case of a pseudo- 
crisis the statement is made that the leucocytes do not drop, and even 
rise. The fall in the leucocytes begins just before, just after, or with 
that of the temperature, and may be preceded by the maximum count. 
Loper claimed two maxima, the one at onset, the other just before the 
fall. They fall by lysis rather than by crisis, reaching normal on about 
the second day. If the temperature falls by lysis, the leucocytes fall as 
a rule more slowly. In cases in which a slight temperature continues 



THE BLOOD: PNEUMONIA 



603 



after the crisis the leucocytes remain elevated until this returns to nor- 
mal. In fatal cases there is often an ante-mortem rise. In delayed 
resolution the leucocytes may stay elevated even for weeks and then 
slowly drop, but in these cases the temperature and leucocytes usually 
become normal at the same time. For the count to remain elevated 
suggests delayed resolution, empyemia, or gangrene. 

A high count gives no idea of prognosis; it means that the pa- 
tient is making a vigorous fight, but gives no hint as to which will win, 
he or the infection. 

In our pneumonia cases the leucocytes are counted twice daily. We have com- 
piled the records of some of these cases (158 uncomplicated cases with recovery, 
56 uncomplicated cases with death, and 80 cases with various complications), 
studying them as regards age and termination. In our uncomplicated cases with 
recovery sex, and the extent of the consolidation have no relation to the degree of 
the leucocytosis. Age has remarkably little influence ; exactly the same percentage 
of cases below forty years had a leucocyte count below 20,000, as of those older. In 
all the uncomplicated cases with recovery, 38 per cent, were below 20,000 ; 7 per 
cent, above 40,000. 

Seventy-seven of these cases terminated by crisis. Of these the cases above 
40 years of age had an average leucocytosis somewhat higher than those younger, 
probably since there were fewer low counts. With 10,000, were no cases ; from 
10,000 to 15,000, 18 per cent.; these were clinically very mild cases; from 15,000 
to 20,000, 25 per cent. ; above 40,000, 8 per cent. There was a sharp rise at crisis 
in 42 per cent, of the cases. 

Of 81 cases with lysis the count during the course was below 10,000 in 2 per 
cent.; from 10,000 to 15,000 in 20 per cent.; from 15,000 to 20,000 in 14 per cent; 
above 40,000 in 10 per cent. There was a sharp rise just at lysis in 34 per cent. 
These rises, which occurred just before the lysis or crisis, were of from 5000 to 
10,000 cells, as a rule, but in a few over 20,000, and in one case 30,000. The 
highest count during the course was 105,500 — a young man 25 years old who 
recovered. 

Of the cases with crisis the leucocytes began to drop before the temperature 
in 15 per cent. ; with the temperature in 41 per cent., and after it in 44 per cent. 
In the lysis cases the drop began before the temperature in 18 per cent. ; with, in 
43 per cent., and after, in 39 per cent., which are practically the same figures as 
for those cases with crisis. To reach normal required in the crisis cases from one 
to twenty days, but the mean time was three days. A well-marked pseudocrisis 
occurred in 9 cases ; of these, 2 were accompanied by a rise of leucocytes, 4 by a 
fall, and 3 by no change. In cases with a slight fever for some days after the drop 
the leucocytes remained from 12,000 to 15,000 until the temperature reached normal. 

There were 56 fatal cases. The leucocyte counts in these were almost the same 
for the various decades as in those with recovery. During the course they remained 
below 10,000 cells in 23 of the cases (in one case they reached even 1700) ; from 
10,000 to 15,000, 23 per cent.; from 15,000 to 20,000, 15 per cent.; and over 40,000 
in one case. At the time of death the count was below 10,000 in 17 per cent. ; from 
10,000 to 15,000 in 25 per cent.; 15,000 to 20,000 in 10 per cent., and above 40,000 
in 8 per cent. ; all the last cases were under thirty years of age. Toward death in 70 
per cent, there was a progressive rise, in 30 per cent, a fall. The absence of leuco- 
cytosis is not necessarily fatal. In one case with extreme toxaemia and a count of 
8000 the leucocytes slowly rose to 14,000 as the patient recovered. 

Daily Variations in the Count. — The two counts were made in the fore- 
noon and afternoon, and separated by an interval of about nine hours. These counts 
differed by from 1000 to 26,000 cells, as a rule from 4000 to 6000, with a mean 
of 4000. There was no difference in these variations before and after the crisis. 
When the temperature was very constant the variation was less marked, the 



604 



CLINICAL DIAGNOSIS 



greatest variation occurring in cases with an irregular temperature, but even then 
there is no parallelism between fluctuations of temperature and leucocytes, in some 
cases even a reverse relation. 

In cases of delayed resolution, in some the leucocytes reached normal before 
the temperature ; in others both temperature and leucocytes were normal before 
resolution was complete ; again, in others the temperature was normal before the 
leucocytes. 

The cases of terminal pneumonia vary much, our series showing two with 
counts above 50,000 and two below 3500. Alcoholics had almost no leucocytosis, 
and yet some recovered. In all cases followed by empyema the leucocytes for the 
most part showed no change which would indicate when the resolution or the 
empyema began. In one case throughout the whole disease and to the time of 
the operation there was no leucocytosis, and in another case the leucocytes did 
not rise at all until the empyema began. In 2 cases followed by pleurisy with effu- 
sion the leucocytes were normal after the crisis (6000 and 8000). In 3 fatal cases 
ending in abscess of the lung the leucocytes were respectively 46,000, 30,000, and 
8500. In 35 cases with various pus infections, endocarditis, pericarditis, meningitis, 
parotitis, otitis media, phlebitis, thrombosis, tonsillitis, etc., very little could be 
learned from the leucocytes ; that is, there was no notable rise, although the fall 
may have been delayed. If already low, they did not rise. 

Qualitative Changes. — The leucocytosis is a rise of especially the 
polymorphonuclear neutrophiles ; they may be even 90 per cent, of all, 
but of our cases they were very seldom above 80 per cent., that is, not as 
high as is general in an inflammatory leucocytosis. The small mono- 
nuclears while relatively diminished are often absolutely much in- 
creased. During the course the eosinophile cells may disappear, but 
after the crisis the polymorphonuclear neutrophiles drop to even below 
60 per cent., and the eosinophile cells increase, but not to a great de- 
gree. Myelocytes appear even in good numbers (almost 12 per cent.), 
and large basophilic mononuclears. In about three clays the percent- 
ages are normal. Loper said that if the polymorphonuclear neutro- 
philes were above 90 per cent, an increase in this percentage meant a 
bad prognosis ; in other fatal cases they may be below 50 per cent. 

Glycogen can be demonstrated in the leucocytes nearly always, in 
amount varying with the temperature and the extent of consolidation, 
in a marked case the majority of the leucocytes being thus laden. 

The platelets may even disappear during the continued fever, but 
after the crisis increase to above normal. 

The fibrin net-work is increased more than in any other disease.. 
Coagulation is rapid. Specific gravity varies as the count and is high. 
The toxicity of the blood is even double. 86 

The diagnostic value of the blood-count is considerable, the pres- 
ence of a leucocytosis excluding malaria and typhoid fever and sug- 
gesting a central pneumonia. It is especially important in the old 
and in the young, and in cases without localizing symptoms, the leuco- 
cytes leading one to search for the physical signs. 

In Intestinal Parasites a slight leucocytosis is the rule. In 12 of 



Albu, Virchow's Arch., vol. cxlix. 



THE BLOOD: ACUTE DISEASES 



605 



our 1 8 recent cases these cells varied from 11,200 to 34,000. In 4 of 
the cases with normal counts there was some fever. 

Bronchial Asthma. — In bronchial asthma the most interesting find 
is an eosinophilia of even 53.6 per cent., which is important in diag- 
nosis, and by means of which the oncoming paroxysms may in some 
cases be predicted. 

In 17 cases during the past four years the red count was high, over 5,500,000 
in 7 cases; the lowest, 4,900,000. There was a leucocytosis of 10,000 to 15,700 in 
6 cases. In but 8 cases were differential counts made, but of these, 6 had above 
5 per cent, eosinophiles ; maximum, 20 per cent, in a total count of 8600. (Of these 
six, the absolute numbers of eosinophiles were 728, 712, 535, 856, 702, and 1720.) 

Acute Articular Rheumatism. — " The blood is the best index of the 
severity of this disease" (Osier). Its virus is a rapid and powerful 
destroyer of the red cells, causing often, but not always, a reduction of 
from 1,000,000 to 2,000,000 cells. Ewing considers that the anaemia 
has been exaggerated. The high count which is sometimes seen during 
the attack may be due to the sweats. This concentration of the blood 
may cover the anaemia, which often is most evident at the time of 
convalescence. Hayem, Tiirk, and others say that the count is lowest 
at the height of the fever, and that regeneration begins at once with 
defervescence. It is rare to find nucleated reds. The haemoglobin 
suffers worse than the red blood-cells. In no other disease is the fibrin 
net-work so thick. 

Leucocytes are increased, as a rule their count running parallel 
to the severity and acuteness of the disease. Cabot's average was 
16,000. 'Changes in the differential count are those of other acute 
diseases. In subacute or chronic rheumatism there is no leucocytosis. 

Of 77 cases of this disease, the red counts were, 2,000,000 to 3,000,000, 3; 
3,000,000 to 4,000,000, 15; 4,000,000 to 5,000,000, 45; 5,000,000 and over, 14; mean 
count, 4,500,000 ; hence very little ansemia. Of 81 cases, the leucocytes were below 
5000 in 1 case, from 5000 to 10,000 in 23, 10,000 to 15,000 in 36, 15,000 to 20,000 
in 15, above 20,000 in 6. 

Another case, a man fifty-six years of age, was admitted with red cells, 
1,720,000; haemoglobin, 27 per cent.; leucocytes, 12,400, He gave the history of 
painful, swollen, red joints four weeks before. He recovered rapidly. 

Arthritis Deformans. — McCrae, in 33 cases, found the average of 
haemoglobin 70.6 per cent.; of reds (29 cases), 4,468,000; the leuco- 
cytes, 7600; the differential count normal. 

Appendicitis. — In acute appendicitis the rule which our surgeons 
follow is the same as for all acute abdominal cases. After the first 
suggestive symptom, or on admission, the leucocytes are counted each 
hour. With a rising leucocytosis an operation is performed without 
delay, even though the abdominal signs are very slight; on the other 
hand with marked abdominal signs the operation is performed, what- 



606 CLINICAL DIAGNOSIS 

ever the leucocytes may be. If the leucocytes are high but stationary 
when the patient is first seen, one can wait ; but if rising, even slightly, 
there should be no delay. A normal count means nothing; the case 
may be mild, very severe, or a well-walled abscess. A high leucocy- 
tosis, 20,000 or above, indicates acute appendicitis, probably an 
appendix full of pus and quite tense. The leucocytes probably fall 
after it ruptures, at least those cases which have recently ruptured 
are admitted with low counts or even a subnormal count, even while 
the process is spreading. In appendicitis 20,000 is a high count, and 
means pus, gangrene, or peritonitis; above 15,000 means an active 
process. In fulminating cases there may be death without any reac- 
tion on the part of these cells. 

In chronic appendicitis with abscess a stationary leucocytosis 
means a well-walled abscess. In those cases with old abscess the 
count is seldom above 12,000, and often from 6000 to 7000, but after 
the operation on such a case the leucocytes will rise at once to about 
20,000 or over and then gradually drop. This is perhaps due to 
exposure of a new area to the infection. If the count remains high 
it means a pocket is still unopened. \\ nile many of our cases with 
well-walled abscess show a normal leucocyte count, yet these cases also 
show marked fluctuations for which no explanation is offered. In 
those cases in which the physical features indicate a rupture of the 
abscess and a spreading peritonitis, the count may rise or drop, or 
may fall even to subnormal, or, after a fall, may then again rise, 
the falling leucocytosis being a worse sign than a high stationary. 87 

In catarrhal appendicitis, and chronic appendicitis without any 
exudate, there is no leucocytosis. 

The red cells show no change except in cases with long standing 
abscess, in which there may be a secondary anaemia. Da Costa men- 
tions an early slight anaemia in most cases, in some a severe anaemia. 

Anaemias of Children. — The study of this subject is of especial im- 
portance, since the blood picture is often so different from that in the 
adult. AYe have even known a diagnosis of lymphatic leukaemia sug- 
gested when the blood was normal. 

Children are much more susceptible to all agencies causing anaemia 
than are adults ; the anaemia is more rapid in development, more 
severe, less easily recovered from. The narrow changes are much more 
strikingly mirrored in the blood, and when regeneration does begin 
the picture is quite spectacular, normoblasts, megaloblasts, and mye- 
locytes appearing in such good numbers. 

The " anccmia of growth'' it is claimed, is explained by the inability 
of the blood-building organs to keep pace with the growth of the 
body. At this time wasting diseases, infections, or any agency del- 
87 See Bloodgood, Prog. Med., December, 1901. 



THE BLOOD 



607 



eterious to the blood, vascular system, or the haematopoietic organs, 
as poor food, bad hygienic surroundings, influence the child much 
more than the adult. The development of the heart and of the whole 
vascular system is also in the closest relation with the blood condition, 
hence chlorosis and other severe anaemias of youth occur in children 
with hypoplasia of the cardiovascular system, and this is attributed 
to a congenital defect. The anaemia of school-children is due to mental 
strain, lack of exercise, poor appetite, constipation, etc. 

A long-standing anaemia in a child is perhaps never perfectly 
recovered from. Objective evidence of it may disappear and the 
child seem well, but relatively insignificant agencies will cause it to 
reappear. 

In all such anaemias of the very young a lymphocytosis is usually 
present and unripe elements appear — normoblasts, myelocytes, and 
large basophilic non-granular leucocytes — which do not occur in the 
normal blood. But these qualitative changes in the blood picture have 
less significance than in the adult, and show more an instability of the 
blood-regulating mechanism. 

The ANEMIA PSEUDOLEUKEMIA INFANTUM of V. Jaksch was 

described as a condition in young children of severe anaemia (even 
820,000; most were 1,500,000 to 3,500,000), with low color-index 
(0.50), a leucocytosis of even 54,660 (in one case, 114,000), with a 
few myelocytes. 

Among the red cells are sometimes many deformed and degener- 
ated ones, and many nucleated reds. The leucocytes are characterized 
by their great variations in form, size, and staining qualities. The 
platelets are increased. 

The best recent discussion of this condition is that of Cabot, 88 
who thinks that the many very different cases thus diagnosed cannot 
be grouped together. They might be cases of pernicious anaemia, 
secondary anaemia with leucocytosis (due to lues, rickets, etc.), or 
Hodgkin's disease, or either of the leukaemias, all of which diseases 
are apt to be atypical in children. 

Bezancon and Labbe emphasize inherited lues as the cause. 

Reckzeh, from analogy from experiments on adult and young dogs, considers 
this form in children a simple anaemia, — that the special features differing from 
that of an adult are due to the reaction of the young. 

Malaria in children causes an especially severe anaemia, with 
normoblasts and perhaps always megaloblasts, but no marked leucocy- 
tosis except perhaps a lymphocytosis. 

Congenital lues causes the severest anaemia, with many nucleated 

88 Fifth edition, " Clinical Examination of the Blood," p. 519. 



608 



CLINICAL DIAGNOSIS 



reds and the lymphocytes much increased, the total count being even 
from 50,000 to 100,000. 

Rickets causes a simple chlorotic anaemia, with the leucocytes even 
30,000, most of them small mononuclears. 

A recent case of anaemia in a fourteen-months-old child is entered on our 
records simply as "Anaemia with enlarged liver and spleen" (Osier). The red 
cells on admission were 1,252,000 per cubic millimetre ; haemoglobin, 20 per cent. ; 
leucocytes, 14,700. The child was in the ward one month, and did not improve at 
all. The leucocytes varied from 13,000 to 26,500, always with the same formula 
(s. m., 40 to 52 per cent. ; 1. m. and tr., 5 to 18 per cent. ; pmn. n., 38 to 62 per cent. ; 
eos., o to 0.9 per cent. ; neutroph. myeloc, 0.9 to 3 per cent. ; Mastzellen, o to 0.2 
per cent. ; nucleated reds, 24 to 250 per 1000 leucocytes, chiefly normoblasts, some 
intermediates, and megaloblasts and microblasts) . 

Such a case resembles the French " splenomegalie chronique avec anemie et 
myelemie." 

Summer Diarrhoeas of Children. 89 — The ordinary summer 
diarrhoeas are usually accompanied by a leucocytosis, but of so wide 
a range that it has no diagnostic value. In the simple dyspepsias the 
differential count of leucocytes is normal (total, 13,500 to 36,000; 
s. m., 39; 1. m. and tr., 21.2; pmn. n., 37.8; eos., 2), but in the 
more severe cases there is an increase in the polymorphonuclear neu- 
trophiles (56 to 63 per cent.), a decrease of the mononuclear cells 
(33 to 7 per cent.), the blood thus presenting the picture of an adult 
blood. In an acute intestinal toxaemia and the severe forms of entero- 
colitis occurs a true leucocytosis. 

A leucocytosis with a wasting disease in a child usually indicates 
an inflammatory intestinal complication. 

Myelocytes are few, eosinophiles sometimes disappear. The leuco- 
cytosis is no indication of the severity of the disease, but the per- 
centage of the various cells is. 

In some cases of severe diarrhoea the red count may rise even to 
10,000,000 cells. 

CHRONIC DISEASES 

Chronic Nervous Diseases.. — These present nothing at all character- 
istic in the blood; in these diseases its condition depends more on 
the general nutritional condition of the patient. 

Some cases of chorea are very anaemic, but the chorea is probably 
not the primary condition. In 23 cases of this clinic there were but 
three with a mild secondary anaemia, the lowest 3,400,000 reds, and 
these were also heart cases. 

There is sometimes an eosinophilia of from 7 to 10 per cent. 
(Theleme). 

In general paresis Capps and Jenks 90 found in some cases just 

89 Knox and Warfield, Johns Hopkins Hospital Bull., July, 1902. 

90 Am. Jour, of Insanity, January, 1900; Diefendorf, loc. cit, 1903, vol. cxxvi. 



THE BLOOD: CHRONIC DISEASES 



609 



before a paretic seizure an absolute leucocytosis, with an increase 
especially of the large mononuclears. In this condition is also some 
anaemia which progresses with the disease, except during the seizure, 
when is seen a temporary rise of reds. 

In maniacal depressive insanity Fisher 91 found often an 
anaemia, almost always a leucocytosis during the periods of excite- 
ment, but no pathognomonic blood-changes. 

In acromegaly there is an increase in reds with eosinophilia and 
lymphocytosis ( Ducati ) . 

Diabetes Mellitus. — The symptoms of this disease are essentially 
those on the part of the blood, and the urinary ones are only secondary, 
the glycosuria being the result of the hyperglycemia, the sugar in 
the blood reaching even 0.57 per cent, instead of, as normally, 0.1 
to 0.2 per cent. 

Concerning the red blood-cells the reports are various. The 
hyperglycemia causes an hydremia, and hence dilution of the blood; 
diuresis, on the other hand, concentrates the blood, hence the actual 
count found varies considerably. Later in the disease, however, as 
the cachexia develops there is an anemia, and yet this anemia may 
be well masked in a concentrated blood. The leucocytes are normal; 
the patients show a remarkable digestive leucocytosis. 

In 45 cases, the red cells were below 4,000,000 in 3 cases ; the lowest was 
2,000,000 ; from 4,000,000 to 5,000,000, 13 cases ; 5,000,000 to 6,000,000, 19 cases ; 
over 6,000,000, 4 cases. Three other cases were at times over 6,000,000. 

Of 40 cases, the leucocytes in 25 varied from 5000 to 10,000; from 10,000 to 
20,000 in 7 cases ; over 20,000 in 7 ; the highest, 44,000. The explanation of the 
leucocytosis was pneumonia, septicaemia, furunculosis, gangrene ; and in a case 
of coma they varied from 30,000 to 41,000. 

Lip^emia is common especially in severe cases. In this condition 
the serum is milky from the increased fat in the blood, this being 
present in dust-like particles, which are sometimes coarse ; the fat is in- 
creased greatly above the normal amount. Bonniger found 0.75 to 
0.85 per cent. ; normal, 1 to 3.25 p.m. ; others in diabetes from 30 
to 117 p. mille; yet lipemia may exist with but 5.5 p.m., and we 
cannot claim an exact relation between the visible and total fat. 
Lipemia is physiological in sucklings, in very obese persons, in some 
pregnant women, and in adults after a heavy fat meal ; but the best 
examples are severe cases of diabetes mellitus with considerable 
sugar excretion, even after a fast of twenty-four hours. It may exist 
for several weeks before death. 

The cause is perhaps disturbed oxidation of the fat present, prob- 
ably the fat of the diet, while others claim the sugar is directly trans- 
formed to fat. Lipemia occurs also in cases of chronic alcoholism, 

81 Am. Jour. Insan., April, 1903. 

39 



610 



CLINICAL DIAGNOSIS 



pneumonia, in progressive tuberculosis, in fracture of long bones, in 
contusions of subcutaneous fat, and, it is said, in some cases of liver 
and kidney disease, malaria, cholera, and phosphorus and carbon mon- 
oxide poisoning. Futcher 92 has contributed a recent article on lipae- 
mia, and Fraser 93 has reported an interesting case with 16.44 P er cent, 
of fat in the blood and 18.94 per cent, in the pleural exudate. The 
record case is Fischer's, with 18.129 per cent, in the blood. 

Bremer's blood-test has proved valuable in certain cases. A 
thick smear of blood is made on a slide, and a similar one for a 
control of normal blood. These are subjected to exactly the same 
treatment. They are first heated to 135 0 C, then allowed to cool 
slowly, and are stained with 1 per cent. Congo red, aqueous solution, 
for two minutes. Relative to the normal blood the diabetic blood will 
take a yellow rather than a red tint. This test is positive also when 
the urine is sugar-free, and is said to be given even before sugar has 
appeared. Schneider found it present in two normal men who were 
great meat eaters, and ascribes it to the reaction of the blood. Strauss 
confirms this opinion, finding it best in cases of acidosis. It is claimed 
to be sometimes present in cases of leukaemia, Hodgkin's disease, and 
Graves's disease, and yet, granting this, it is of importance in 
diagnosis. 

In this clinic a man was admitted during coma ; no urine could be obtained 
by catheterization ; the diagnosis of diabetic coma was made from this test alone, 
and confirmed later by autopsy. 

Williamson's Test. — Twenty cmm. of blood in a test-tube are mixed with 
1 cc. of aqueous methylene blue (1 to 6000) ; 40 cmm. of 60 per cent. KOH and 
40 cmm. of water are added. This mixture is allowed to stand for three or four 
minutes in boiling water. If the blood be diabetic it takes a yellow color. 

Quantitative Determination of Fat in the Blood. — The method chosen by 
Bonninger, in Salkowski's laboratory," 4 is as follows : From 5 to 30 gm. of blood 
are mixed with 10 to 20 volumes of 96 per cent, alcohol, the precipitate ground fine, 
then allowed to stand one or two days. It is then filtered, the precipitate again 
extracted several times with alcohol in the same way, then with 5 to 10 volumes 
of ether twice, digesting one day each time. All these extracts are then com- 
bined, evaporated, repeatedly taken up in absolute alcohol, and this evaporated, 
then filtered, dried, and weighed. Extracting twice with alcohol alone will give 
96 per cent, of the total fat. 

Malignant Disease. — Malignant diseases are the most important 
anaemia-producing diseases. The immediate cause of the anaemia may 
be the frequent hemorrhages, the mechanical effects of the cancer, 
and this is well seen in gastrointestinal cases, and, most important, 
the cancer toxine. That the toxine is the most important factor is 
shown by the extreme anaemia caused by a small latent nodule which 
can cause no local symptoms. The result of the growth is an anaemia 

92 Jour. Am. Med. Assoc., October 21, 1899. 

93 Scot. Med. and Surg. Jour., 1903, p. 200. 
94 Zeits. f. klin. Med., 1901, vol. xlii. 



THE BLOOD: CHEONIC DISEASES 



611 



parallel to the progressive cachexia. And yet it is remarkable how 
long the blood will present an almost normal picture before the slight 
anaemia begins, and then how rapidly the anaemia and cachexia will 
develop. Grawitz claims that the cancer produces a plasmotropic 
poison ; that is, one which may affect the blood, or the blood plus the 
body tissues, or the tissues without the blood, producing in some cases 
merely degenerations of the red blood-cells ; in other cases an anaemia 
parallel to the cachexia ; in still other cases a marasmus of the highest 
grade yet with the blood only slightly affected. 

Cancers vary much. Some, for instance those of the skin or lip, 
cause no anaemia, while a fulminating cancer, as of the stomach, 
" may give a perfect picture of primary pernicious anaemia, or, indeed, 
of leukaemia." In general it is stated that the more malignant the 
tumor the greater the blood changes, and the more extensive the can- 
cer, that is, the more its metastases, the greater its influence upon the 
blood. But this is not entirely true : our cases with rapidly developing 
metastases, with large nodules, are those with a slight chlorotic 
anaemia; those which simulate pernicious anaemia are more often 
cases with few if any objective signs of cancer, and at autopsy one 
finds an insignificant looking little nodule. 

The common picture is the so-called " pseudo-chlorosis carcinoma- 
tosa;" others show the picture of the severest pernicious anaemia, 
the cases being thus diagnosed, and the diagnosis corrected at the 
autopsy by a small cancer nodule, often of the stomach, which before 
that was unsuspected. In still other cases no anaemia results. Cabot 
says in one-half the cases there is a chlorotic anaemia; in about one- 
fourth, none; while one-fourth show a reduction in both count and 
haemoglobin. 

The severest anaemia occurs in those cases with frequent hemor- 
rhage, as, for instance, of the stomach and of the uterus. Anaemia 
from cancer of the digestive tract is sometimes great because of the 
resulting malnutrition, v. Limbeck says that it is common, and perhaps 
the rule, to find even in advanced cases blood which is qualitatively 
normal ; that in cases with dessicated tissues there may be even a rise 
in the count; and in advanced cachexia cases without hemorrhage 
there is seldom much diminution in the red count. 

The anaemia when it does occur is of the secondary type as a rule, 
and severer than that due to any other chronic disease. The chief 
changes are at first in the size, shape, weight, and degeneration of the 
red blood-cells; later, as the cachexia develops, the anaemia is often 
as low as 2,500,000 cells, or even as low as in pernicious anaemia, 
1,000,000 cells. An exception to this is in cancer of the oesophagus, 
where, indeed, the blood may be concentrated. 



G12 



CLINICAL DIAGNOSIS 



There is a constant and often an early reduction in the haemo- 
globin. Its percentage may be normal but then the count will be found 
above normal; the average in long-standing cases is about 68.5 per 
cent., in worse cases 57.5 per cent. It is, therefore, rarely as low as 
in chlorosis. This low haemoglobin is an important diagnostic point 
between malignant and non-malignant tumors. Cabot's average was 
58 per cent., with an index of 0.65. The haemoglobin is lower in 
cases of visceral than peripheral cancer, and the index is low even in 
severe cases ; yet Bezancon and Labbe mention two cases in which the 
cells were increased in size and with an index over 1. After opera- 
tion regeneration begins at least one week later than would be expected, 
and it is said never quite to regain the percentage it was before opera- 
tion, even though the patient gains in weight (Bierfreund). 

There is always diminution in the average size of a few or most of 
the cells. The giant cells of pernicious anaemia are rarely seen here 
except late, while microcytes are common (Grawitz). The basophile 
granulation is very common. The deformities in size and shape and 
all degenerations may be absent or they may be even more marked 
than in tuberculosis, in which case they are of diagnostic value; they 
are a less prominent feature, however, than of pernicious anaemia. 
Nucleated reds are present as a rule and always in the severe cases. 
They are more numerous than in secondary anaemias due to any other 
cause, and are found even when the anaemia is slight. Their pres- 
ence has some diagnostic value in a differential diagnosis between 
cancer and ulcer of the stomach. They are normoblasts, as a rule, 
although in those cases which simulate pernicious anaemia a few mega- 
loblasts may be present. In cases involving bone-marrow their number 
may be enormous, even 90,000 per cubic centimetre (Turk). 

The blood is hydraemic, with reduced albumin. Metabolism ex- 
periments indicate an abnormal destruction of tissue proteid, the evi- 
dence of a circulating toxine. Grawitz suspects that in some cases the 
anaemia is only apparent, since the injection of carcinoma extract shows 
that the tissue lymph will dilute the blood. But this others doubt. 
Much of the anaemia is due to repeated hemorrhages, which are 
common enough, yet there is all the evidence necessary of a haemolytic 
toxine. 

Leucocytes. — In general, in about 60 per cent, of all cases, there 
is a moderate leucocytosis, an important point in the differentiation 
of benign and malignant tumors, and this may be the first sign of 
cachexia. Of some the count is normal ; some present the appearance 
of leukaemia. This leucocytosis depends upon the hemorrhages and 
the position of the cancer. In oesophageal stricture the starvation will 
sometimes cause a leucopenia. and the cells present will be chiefly 
lymphocytes ; in cancer of the uterus and stomach so commonly accom- 



THE BLOOD: MALIGNANT DISEASES 



613 



panied by hemorrhage, a post-hemorrhagic leucocytosis is common; 
in those of the thyroid, pancreas, and kidney the count is especially 
high. It also depends upon the size of the cancer, including of course 
the metastases ; the larger and faster the tumor grows the more the 
leucocytosis; but there are great variations. Grawitz, from his injec- 
tion experiments with cancer extract, considers that the increase is 
due to the entrance of the tissue lymph into the blood-stream, carrying 
with it a great many leucocytes, the same which occurs in a post- 
hemorrhagic leucocytosis, and hence considers that the leucocytosis is 
coincident with the softening of a tumor mass. After operation the 
leucocytes drop, and their subsequent rise may indicate a recurrence 
even before it can be found physically. 

Differential Count. — As a rule, a leucocytosis means an in- 
crease of the polymorphonuclear neutrophiles, but in some cases these 
are low, even 43.7 per cent., and the lymphocytes are increased. In 
other cases there is a leucopenia of even 3000, but with the poly- 
morphonuclear neutrophiles even 88.7 per cent. The eosinophiles are 
not usually as much diminished as in other leucocytoses, but on the 
other hand, they may not be increased even when bone metastases are 
present. Myelocytes are more commonly present in cancer than in 
any other condition excepting leukaemia and pernicious anaemia. 

The specific gravity of the blood is low. The plasma is rich in 
sugar, even as rich as in diabetes. Its alkalinity is decreased even 
to one-third. The coagulation is normal or retarded unless sloughing 
or inflammation be present, in which case it may be rapid. The fibrin 
net-work is usually normal. 

It is said that the effect of cancer is seen in degenerative changes 
of the leucocytes before the quantitative changes begin. 

In cancer of the breast a slight leucocytosis (11,000) is com- 
mon. In cancer of bone are found very many nucleated reds, nor- 
moblasts and megaloblasts, and leucocytosis with a high percentage of 
mononuclears, and some myelocytes. 

Cancer of the Stomach. — A cancer of the stomach may cause a 
blood condition which resembles closely primary pernicious anaemia. 
In these cases the red cell count may be very low, even 500,000 per 
cubic millimetre (Grawitz). But such cases are rare. Cabot found 
that of 129 cases, in 27 the count was above 5,000,000, in 26 below 
3,000,000, and that the average of all on the first examination was 
4,018,000. Of the 134 cases of this clinic, including those reported 
by Osier and McCrae, in 33 it was above 5,000,000, in 16 below 3,000,- 
000, and the mean was about 4,000,000. The color-index is always 
considerably below unity unless the count be very low. Nucleated 
reds were rather rare. The count sometimes drops progressively till 
death (in one case to 1,786,000). The high counts are sometimes 



614 



CLINICAL DIAGNOSIS 



attributable to the vomiting. The differential diagnosis between can- 
cer of the stomach and pernicious anaemia is one of well-recognized 
difficulty, and in many cases can be settled only at autopsy. In general 
it may be said that in pernicious anaemia there is a lower count; that 
if the red blood-cells are below 1,500,000 it is against cancer; yet this 
rule is a broken reed, for it fails in both directions. Cases most like 
pernicious anaemia have small insignificant cancer nodules, and without 
autopsy would pass as primary anaemia. After autopsy one can by 
retrospect see minor points which should have led him to suspect 
cancer, but only then. In cancer the index is generally below one ; 
there are fewer nucleated reds and those that are present are normo- 
blasts as a rule; and leucocytosis is more common. In cancer the red 
blood-count is always higher than the cachexia would lead one to 
suppose, in pernicious anaemia the reverse. The blood examination 
Henry thinks of greater value in this differential diagnosis than the 
gastric analysis. The leucocytes in this disease vary so greatly and 
so without apparent explanation that little value can be placed on 
this count, except that there is a leucocytosis in over one-third of the 
cases, and in those without it the digestive leucocytosis is often absent 
(in 82 per cent, of 144 cases, yet this is of little really practical value, 
although it is one point to consider — Da Costa). Low counts, below 
4000, are not rare. The highest of our series was 52,800. 

It is said that the rapidity of growth controls the count, and yet our lowest 
counts included those certainly with metastases in liver, pancreas, or peritoneum 
(1600, 5400, 5000, 5600), and in 15 cases of cancer of the liver or abdominal organs 
generally the leucocytes were above 10,000 in but 7. In one case, 105,000 
(t.° 103 0 F.) ; in another, 24,500 (t.° 99 0 .) ; just before death in a third, 61,400. 
The high counts were nearly all in those with the slight fever so often present. 

Cabot reports a case with perforation into the peritoneum followed by quickly 
fatal peritonitis and a count of 105,600. We suspected this condition in a case the 
count of which rose to 120,000, an almost pure leucocytosis, but were unable to get 
an autopsy. 

The percentage of large mononuclears has been found rather high (1 to 10 
per cent.) ; in one case before death even 33 per cent, of a" total count of 6300 
(Kurpjeveit). 

In carcinoma of the oesophagus the blood is concentrated, giv- 
ing a high content of dried substances; in v. Noorden's cases, 26.5 
and 27.3 per cent. And yet in these cases there may be an oligaemia. 
If the cancer extends to the larynx, causing dyspnoea, the count may 
be high from the cyanosis. 

Of our 6 recent cases, in one case the red count was 5,960,000, the lowest 
4,184,000, and in another the first blood examination gave 4,696,000, 85 per cent, 
haemoglobin, 6000 leucocytes ; a later count was 6,476,000, 104, and 19,000 re- 
spectively. Five of the cases showed a leucocytosis, the highest 30,250. In 15 
cases of cancer of the liver or general carcinosis of the abdominal organs, 
cases in which one might assume there was rapid and extensive growth, in but 
two was the red count below 4,000,000. In 27 cases of cancer of the bile-ducts 



THE BLOOD: MALIGNANT DISEASES 



615 



the lowest red count was 3,700,000, and in five the leucocytes above 10,000 ; in 
one case, 44,150 (t° ioo° F.). 

In 4 cases of cancer of the rectum the reds were scarcely- 
reduced (lowest, 3,732,000, the rest about normal). There was a 
leucocytosis in two cases [13,100 and 19,750 (t° ioo° F.)]. 

In 10 cases of cancer of the intestine 3 showed marked anae- 
mia; in one, reds 1,600,000; haemoglobin, 40 per cent.; leucocytes, 
2500; situation, the ileum: the other had 1,780,000 reds, 28 per 
cent, haemoglobin, and 10,000 leucocytes; this patient was a nephritic 
as well: the third, reds, 1,609,000; haemoglobin, 40; leucocytes (one 
week before), 7500; situation, the sigmoid flexure. The other red 
counts were from 4,000,000 to 4,500,000, four cases; the highest, 
5,348,000; but 2 of the 9 showed a leucocytosis. 

Our other cases of carcinomata showed no striking features, ex- 
cept one of the testicle, with 2,832,000 red cells and 9600 leucocytes. 
Cancers of the kidney show usually high leucocyte counts, even 
54,000. We had no such case. Also of the thyroid (71,000), and 
some of bone (52,700). 

In sarcoma there is in general the same condition as in carcinoma, 
but some think that the effect on the blood is worse. We could not 
believe this from the study of our cases. This may be true particu- 
larly if the bone-marrow or the lymph-glands are especially involved; 
then a severe anaemia and high leucocytosis are the rule. In a case 
of osteosarcoma the red blood-cells were 663,400 (Hayem) ; in 
another case, 1,118,000; haemoglobin, 28 per cent.; leucocytes, 68,- 
200. In still another case, 2,240,000; haemoglobin, 48 per cent.; 
and leucocytes, 54,000 (v. Limbeck's two cases). Yet other cases 
have counts even above 6,000,000, while still others present the 
appearance of a primary pernicious anaemia. The nucleated reds are 
said to be less numerous than in carcinoma. The haemoglobin is said 
to be more reduced than in other cancers, the average being about 50 
per cent., with 30 per cent, not rarely, while cases even below 10 per 
cent, are reported. The leucocytes in cases of osteosarcoma average 
about 1 7,000. They are more constantly increased and to a greater de- 
gree than in cancer, the cases resembling leukaemia. Among the qual- 
itative changes an increase in the polymorphonuclear neutrophiles is 
less common than in cancer, but it may be present when there is no leu- 
cocytosis. This is said to have diagnostic value as against cancer. In 
some cases there is a large percentage of eosinophile cells, even 50 
per cent., with little evidence that it is due to bone metastases. Mye- 
locytes are sometimes increased. The old question whether all these 
cells are leucocytes or free sarcoma cells recurs often, for the increase 
often seems clue to the small mononuclears. 

Lues. — Lues, according to v. Limbeck, is the best illustration of 



616 



CLINICAL DIAGNOSIS 



the dictum that no blood picture can be considered characteristic for 
the anaemia due to any one disease. In this case the blood picture 
may be the most varied, simulating anything from chlorosis to per- 
nicious anaemia. The anaemia is particularly striking in the case of 
women. At first of the chlorotic type, it may at the end simulate a 
pernicious anaemia even of the severest grade, with a count of 428,- 
000 cells ; some cases of acquired lues have a practically normal blood, 
but this is unusual. 

It is important not to confuse the anaemia due to the disease with 
that due to vigorous mercurial treatment. In a severe and protracted 
untreated case the chlorotic anaemia may reach an extreme grade, and 
then improve gradually. 

During the primary stage a severe chlorotic anaemia is the rule, 
and any one following large European skin clinics is struck by the 
importance that is placed upon this anaemia, particularly in the case 
of women, in the diagnosis of a primary sore. Some say that the 
count will remain normal while the haemoglobin diminishes consid- 
erably. During the transition from the primary to the secondary 
stage, one of the first signs of the dissemination of the disease through- 
out the whole body is the appearance of the rash and a further 
diminution of haemoglobin. Yet the count remains nearly normal, 
while in a few days there may be a loss o^f haemoglobin of 25 to 30 
per cent. If untreated, the haemoglobin soon may be as low as 25 
per cent., and red blood-cells also drop, even at the rate of 230,000 
cells per day. The severity of the anaemia depends on the condition 
of the patient, age, treatment, etc. In well-treated cases a rapid 
regeneration follows. 

Leucocytes. — During the tertiary stage with severe anaemia there 
is often a leucocytosis with a high lymphocytosis. Myelocytes are 
present in a severe case. This leucocytosis is an aid in excluding 
pernicious anaemia. 

In an adult a high lymphocytosis and an eosinophilia suggest 
lues. In a child this blood picture might suggest rickets also. A low 
haemoglobin per cent, and a high percentage* of small mononuclears 
indicates a severe case. 

In the primary stage the leucocytes are normal, or there is a slight 
leucocytosis with an increased percentage of lymphocytes. If mer- 
cury be given the percentage of the polymorphonuclear neutrophiles 
rises, the reverse of the action of mercury in a normal case. 

During the secondaries the leucocytes vary from 12,000 to 16,000, 
the lymphocytes and eosinophiles are increased, the latter especially 
with the papular syphilide. 

In 19 cases of secondary lues the red cells were diminished but slightly (mini- 
mum, 4,200,000; above 5,000,000 in 6), the haemoglobin was evidently more affected 



THE BLOOD: CHBONIC DISEASES 



617 



(40 to 90 per cent.; mean, 75 per cent.; color-index, 0.5 to 0.9; mean, 07), the 
leucocytes, as a rule, were normal (in 11 cases below 10,000, in 3 between 10,000 
and 12,000), except in cases of high fever (leutic fever of secondary stage), of 
which there were 5 cases, in four with the leucocytes between 12,000 and 24,000, 
and dropping with the temperature. 

There was a slight rise of leucocytes during the primary stage (average 9000). 
During the secondaries the count, depending on the skin lesion and the fever, varied 
from 9000 to 24,000, or even 50,000; average, 12,000 to 15,000. During the tertiary 
stage the counts varied greatly ; in some cases there was a slight rise, in others a 
leucopenia. In hereditary lues the count has been found high, — 12,000 to 24,000. 

In hereditary and tertiary lues the red cells are seriously affected, 
in number, size and color. Megaloblasts are common. The blood 
picture, especially of the long-standing cases with much scarring 
of the organs and sclerotic bone-marrow may resemble primary per- 
nicious anaemia. But in these conditions, as in cancer, the megalo- 
cytes do not predominate as they do in pernicious anaemia. Many 
cases in children reported as leutic anaemia were probably anaemia 
pseudoleukemia infantum. Miller reported a case with 720,000 reds, 
18 per cent, haemoglobin, with normoblasts, megaloblasts, even gigan- 
toblasts, microytes, and poikilocytes. In the hereditary lues of infancy 
the anaemia may be fatal. The average leucocyte count of 25 cases 
was 7050. Large nucleated reds containing little haemoglobin are 
important (Cima). 

Following mild mercurial treatment the cells rise even 100,000 cells 
a day, the rise sometimes ending in even a slight hypercythaemia. 
But the rise is often preceded by a drop (since those red cells in- 
jured by the disease are first destroyed by the mercury?), hence some- 
times a hemoglobinuria and a drop in the count immediately after 
the inunction, followed by rapid regeneration and improvement in the 
general condition. If the treatment is carried too far it may itself be 
the cause of an anaemia. The length of treatment is therefore set 
at twenty-four days by some (Gaillard), but the individual varia- 
tions are considerable. Conried advised from twenty-five to thirty- 
five inunctions; others say to give these ad libitum. In general the 
count rises for fourteen days, and if the mercury is continued begins 
to fall in twenty-four days. 

Of 23 of our cases, 7 of which were of cerebral lues, the red cells 
were above 5,000,000 in 9 cases, between 4,000,000 and 5,000,000 in 
10, and the lowest count 2,870,000. The color-index varied from 
0.4 to 0.9; mean, 0.67. The leucocytes were below 10,000 in 20 of 
29 cases. They varied from 10,000 to 18,500 in the other 9 cases; 6 
were cases of high luetic fever; one was the malignant type (16,800, 
no fever) ; the case with 18,500 had large gummata. In one cerebral 
case the leucocytes were 3000, in another 2100. 

Justus's Test. — A large inunction or injection of mercury given 



618 



CLINICAL DIAGNOSIS 



a case of lues before the rash, yet at a time when the general enlarge- 
ment of the lymph-glands shows that the toxine is now disseminated 
throughout the whole body, is followed by an immediate drop in the 
haemoglobin of from 10 to 20 per cent., and then a rise to normal or 
even above normal, in from one to several days, with improvement of 
all the symptoms. This drop, which is both rapid and considerable, is 
specific for a case of florid lues (but Cabot found it in a case of chloro- 
sis). It may be obtained in any form of lues, late primary, secondary, 
tertiary, or hereditary, provided the disease be at that time florid, but 
not when or just before the symptoms begin to recede, as with cicatri- 
zation, desquamation, etc. It may again be obtained in case of relapse 
and until it has passed its climax. It is not present during the primary 
stage, so long as the infection is limited to the chancre and its neigh- 
boring glands, but only after the toxine has become generally spread, 
as shown by the swelling of distant glands. It cannot be used early to 
differentiate a hard and a soft chancre. This will explain the dissatis- 
faction many have with the Justus test. 

As explanation it is thought that the mercury kills off the dam- 
aged red blood-cells which are soon replaced by new ones. 

This test which promised so much has been repeatedly tried by 
various men. Many fail to get it in cases which turn out to be lues, 
yet in nearly all of these cases the test may have been applied too 
soon. Others have found the test in other diseases ; for instance, 
Brown and Dale, Jones, Da Costa, Cabot, and Huger. Justus has 
lately reiterated his claim for its specificity, 95 and certainly answers 
well his critics. While the test may not be pathognomonic, it is still 
valuable. 

Renal Disease. — The kidneys play an important part in the control of 
the composition of the blood, hence in nephritis the plasma changes 
are early and most important : a loss of albumin, lowered specific 
gravity, and in general all the signs of a chronic secondary anaemia. 
This may in part be due to the actual loss of albumin in the urine, the 
" serous hemorrhage" of some writers, but in acute cases, perhaps 
chronic, there is evidence of the presence of a toxine. 

In the acute hemorrhagic nephritis especially the count may 
be very low, even 1,000,000, but usually the anaemia is moderate, and 
of this much is only apparent. 

In 12 recent cases of acute nephritis there were .but two low counts, 2,600,000 
and 2,000,000; a leucocytosis in five, 11,400 to 18,900. In Cabot's 50 cases, the 
lowest red count was 3,568,000, but the leucocytes were above normal in 31 of the 
cases; highest count, 50,000. Cabot thinks the leucocytosis due to hsematuria or 
ursemia. But nephritis is an acute febrile, and perhaps infectious disease, and a 
leucocytosis is to be expected. 

95 Deutsches Arch. f. klin. Med., 1903, vol. lxxv. p. 1. 



THE BLOOD: CHEOOTC DISEASES 



619 



In chronic nephritis so many factors come into play that the 
blood picture is not clear. Yet the influence of nearly all these factors 
is to cause anaemia. Among them is the condition of the heart; the 
oedema and hydremia; the wretched condition of the gastrointes- 
tinal tract, vomiting, diarrhoea, poor appetite, and the influence of the 
purges. The result is often a lowered count, a still more lowered 
haemoglobin, and an hydremic plasma. 

In 103 cases of chronic nephritis the red cells were 1,700,000 in one case, between 
2,000,000 and 3,000,000 in 13 cases, between 3,000,000 and 4,000,000 in 25, over 
5,000,000 in 19; mean, 4,500,000. 

The haemoglobin in 99 cases was between 20 and 30 per cent, in 3 cases, from 
30 to 50 in 29, above 80 per cent, in 17; mean, 62 per cent. ; hence the mean color- 
index, 0.7, which is almost normal. 

The leucocytes in 80 cases without uraemia were below 5000 in 4 cases, 5000 
to 10,000 in 43, above 10,000 in 33, and of these the highest were between 20,000 
and 30,000. 

In 33 cases with uraemia the highest was 25,900, above 10,000 in 15 cases, below 
5000 in 2; mean, about 9000. It is seen that in our cases those with uraemia did 
not differ much from those without. 

A most interesting group is of the cases somewhat resembling 
pernicious anaemia, and with only nephritis to explain the condition. 

A case from this clinic 96 is a good illustration of this, or of the simultaneous 
occurrence of the two diseases. The patient was a man 39 years old ; red cells, 
1,400,000; haemoglobin, 27 per cent.; leucocytes, 7000 (pmn. n., 88 per cent.; s. m., 
8 per cent.; 1. m., 2 per cent.; eosinophiles, 2 per cent.). There was no poikilocy- 
tosis, and but one nucleated red found. The urine was of low specific gravity, with 
much albumin and many casts. 

Cabot reports such a case with 1,468,000 reds ; haemoglobin, 23 per cent. ; leu- 
cocytes, 3800 (pmn. n., 70 per cent.; s. m., 23 per cent.; 1. m., 4.4 per cent.; eosino- 
philes, 2.6 per cent.; megaloblasts, normoblasts, and poikilocytes) . 

In the case of Labbe the red blood-count was 500,000 ; haemoglobin, 2 gms. ; 
the cells pale, irregular in form and size ; nucleated reds rather small ; mono- 
nuclears, 59 per cent. Recovery was rapid. He suggests that the anaemia was for 
the most part that of dilution. In another case the red blood-cells were 418,500 
and the color-index over 1 ; and in a third the count was 1,000,000. At autopsy 
in such cases nephritis is the only lesion found. There were practically no signs 
of blood destruction, nor of regeneration, nor of megaloblastic degeneration of 
the marrow. It is a question how much of the low count the hydraemia will 
explain, but there is certainly some relation between the anaemia and the oedema, 
and the hydraemia which accompanies the anaemia. 

We mention two other cases with arteriosclerosis and chronic nephritis. 
One was a woman, fifty-four years of age, with reds, 2,800,000; haemoglobin, 50 
per cent. ; leucocytes, 6000 ; no fever. The other was a man thirty-two years old, 
with reds, 1,772,000; haemoglobin, 22 per cent; leucocytes, 50,000 (of which 91 per 
cent, were pmn. n.) ; the leucocytes later rose to 116,000; he left the hospital 
unimproved. 

In interstitial nephritis the count is normal at first, and sometimes 
to the end. The condition of the heart is important During the 
acute exacerbations, however, a slight lowering of the count is com- 
mon, perhaps due to the hydraemia. 

96 McCrae, Johns Hopkins Hosp. Bull., October, 1902, p. 245. 



620 



CLINICAL DIAGNOSIS 



In bilateral cystic kidxey there was anaemia in both of 2 cases, 
4,200,000 and 2,800,000; a leucocytosis of 13,500 and 36,000. 

Diseases of the Liver. Catarrhal Jaundice. — " Occasionally there 
is a slight leucocytosis at the onset, otherwise normal blood, with 
some degenerative changes in severe cases" (Cabot). An increased 
resistance, rigidity, and size is claimed for the red cells. 

Of 27 of our cases, the red count was normal or even above normal in 16 ; 
the lowest, 3.000,000 ; the mean, 5,000,000 in the male patients. An interesting 
feature was the rise in the count of 300.000 to 750.000 cells while in the hospital. 
Of the 27 cases, in 20 the leucocyte count was 10.000 or below ; in 3, from 10.200 
to 10.500; and in 4 from 14,200 to 19.500; these cases all with slight temperature. 
The cells fell rapidly to normal after admission. A leucopenia follows in some 
cases (Bezangon and Labbe). 

The plasma of the centrifugalized blood is bile-stained. Coagula- 
tion time slow. 

Toxic Jaundice. — Of this we had three fatal cases. Of one, 
the red cells were 3,570,000; haemoglobin, 65 per cent.; leucocytes, 
11.400: the second, 5,280,000, 75 per cent., 7000: and the third, 
5,400,000, 65 per cent., and 12,500 respectively. 

Gall-Stones. — A mild leucocytosis during the attack of colic is 
very common, a high one rare. During the colic the count in our cases 
(36 in number) took a sudden jump to about 15,000, but in cases of 
stone in the common duct with the chills and fever, it was higher, even 
24,700. The red cells varied from 2,800,000 to 6,400,000; mean, 
4,300,000. In a case with hemorrhage they fell to 1,880.000; haemo- 
globin, 23 per cent. ; leucocytes, 17,500. The coagulation time should 
be tested before any proposed operation, and if found lengthened 
calcium lactate may be given until it is normal. 

Cholecystitis. — The leucocytes are invariably high, from 20,000 
to 27,000 (Bloodgood). In one of our cases the count was 46,500. 
As the case becomes chronic the count falls nearly or quite to normal. 

Cholangitis. — Of 5 cases the leucocytes were 16,000, 33,160 
(fatal), 15,600 (t.° 103. 5 0 ), 9000 (t.° 103 0 ), and 6,400 (t.° 106 0 
— fatal). 

Abscess of Liver. — During the acute process the leucocytes may- 
be high, but later are lower, or normal when the temperature is nor- 
mal. Futcher 97 found the average in 15 cases to be 18.350, the 
maximum 53.000. The reds were 2,600,000 to 5,600,000, mean, 
4,200,000; mean of haemoglobin, 60 per cent. 

Cirrhosis of the Liver (Atrophic). — Early there is no change 
in the red cells, later an anaemia. Da Costa's average, 3,404.000: 
Cabot's, 3,580,000; and one case, 1,300.000. The leucocytes are nor- 
mal or low. In our 32 cases the red cells varied from 3,100,000 to 
97 Jour. Am. Med. Assoc., August 22, 1903. 



THE BLOOD: CHRONIC DISEASES 



621 



5,900,000, mean, 4,500,000; haemoglobin mean, 68 per cent. Leuco- 
cytes in 30 per cent, of cases, over 10,000; the highest, 16,000. 

Hypertrophic Cirrhosis (of Hanot). — Hayem reported a case 
with extreme anaemia. We have had five cases ; in 2 the count was 
high, 7,800,000 and 8,500,000; and in one as low as Hayem's case, 
1,504,000; haemoglobin, 28; leucocytes, 6100 (the count rose later). 
In two there was leucocytosis (11,000 and 12,800). 

Acute Yellow Atrophy. — The cases reported have had normal 
red blood-counts and moderate leucocytosis. In a recent case of this 
clinic, a boy 14 years old, the reds were 4,800,000 and leucocytes 
12,700. 

Leprosy (v. Limbeck). — Early no change is noted, but after a few 
years develops usually a pseudochlorosis with a normal count. After 
general malnutrition begins the anaemia becomes more marked, and 
yet is rarely very severe (in one case, however, 2,290,000 red blood- 
cells, 55 per cent, of haemoglobin). Leucocytosis has not been found, 
these cells varying from 4000 to 8000 per cmm. 

Heart Disease. — While compensation is good the blood is normal, 
but with acute loss of compensation and a low blood-pressure the blood 
is hydraemic, hence the count is low. With, however, the chronic 
stasis which follows, and the cyanosis, the blood-count rises and may 
conceal an anaemia. The worst anaemia is seen in aortic valvular in- 
sufficiency, as in a case with reds, 3,400,000; haemoglobin, 30; leuco- 
cytes, 8000; and if the blood condition improves the heart may regain 
its compensation. In congenital heart disease with extreme cyanosis 
the condition of the blood is particularly interesting, as it is in these 
cases that we get not rarely a polycythaemia with red cells between 
eight and nine millions. 

During the loss of compensation in 29 males with pure mitral disease the count 
varied from 3,000,000 to 7,500,000, and the mean 6,200,000. In 46 women the mean 
was 4,700,000, but the extremes, 3,500,000 and 8.000,000. There were interesting 
jumps of from 1,000,000 to 2,000,000 cells while under treatment. 

In 37 cases of pure aortic disease the mean was 5,200,000; these 
cases showed a lower blood-count, as a rule, on each admission. 

In 29 cases of arteriosclerosis (no important cardiac lesions) the 
mean was also 5,200,000. In 34 cases of aneurism of the thoracic 
aorta the mean was 5,500,000; in five men with aneurism of the 
abdominal aorta, 4,500,000. 

Addison's Disease. — A hypocythaemia is the rule, the cells varying 
from 2,000,000 to 3,000,000; in one case 1,120,000; in other cases, 
however, the reverse is true, and the count may be even above 7,000,- 
000. Some consider that the anaemia is due to a complication, and 
not to the disease itself. Others, that there is always an oligaemia, 



622 



CLLNICAL DIAGNOSIS 



but that this is covered by the concentration of the blood, and cite a 
case with true oligsemia and a count of 4,774,000 cells. 

Myxcedema. — In myxcedema the count may be increased, dimin- 
ished or normal. Many find an ansemia which improves with treat- 
ment. Some have found an increased diameter of the red blood-cells, 
which decreases under treatment, also many nucleated reds; that is, 
an infantile condition of the blood. The platelets were in a recent case 
much increased. 

Rickets. — Ansemia is the rule, generally of a mild grade, but some- 
times intense, rapid, and even pernicious. 

Scurvy. — The count varies generally from about 3,000,000 to 4,- 
000,000 cells. If the case is accompanied by much hemorrhage the 
ansemia is more intense. In Buchard's case, after three weeks with 
considerable epistaxis, the count was 557,000. In some grave cases 
macrocytes, microcytes, and fragmented reds are found. The color- 
index is reported low. 

The Value of Blood Examination. — A question, much discussed 
recently is the " value " of blood examination. But by " value " is 
usually meant the " practical use " which may be made of it, and not 
any interesting yet " useless " information it may throw on the case. 
The question is a fair one, especially since vast numbers of pages have 
been printed to prove blood counting indispensable. 

The first point we wish to emphasize is that blood examination is. 
of much greater value to the medical man than to the surgeon. The 
internist cannot dispense with it; the surgeon can. Some diseases 
are best diagnosed in this way. Among them are malaria; especially 
the forms without definite paroxysms and with atypical course, which 
pass otherwise as typhoid fever, meningitis, ursemic coma, pernicious, 
ansemia, appendicitis, tuberculosis, dysentery, even Raynaud's dis- 
ease (cases with superficial gangrene), the long list of diseases which 
atypical pernicious malaria may simulate, and failure to recognize 
which results in the unnecessary death of patient. Trypanosomiasis, 
and infections with the Leishman-Donovan bodies can be recognized 
only by splenic puncture. Pernicious ansemia is quite uniformly over- 
looked without blood examination, and the cursory glance at a fresh 
blood specimen sometimes saves the patient from a course of treat- 
ment for jaundice, peripheral neuritis, or tabes, with which diagnosis 
patients are repeatedly admitted here. Blood examination is necessary 
for the diagnosis of splenomyelogenous leukaemia, and that this has a. 
practical value is shown by the fact that the majority of our cases 
come to the surgical side for abdominal tumors (enlarged spleen), 
and are sent to us after a glance at the fresh blood. The diagnosis 
of lymphatic leukaemia, acute leukaemia, or pseudo-leukaemia, can be 
made only in this way. 



THE BLOOD: CHEONIC DISEASES 



623 



For the early diagnosis of typhoid fever, measles, scarlet fever, 
etc., the leucocyte count is valuable, the absence of leucocytosis being 
much more suggestive than its presence; also in acute epidemic cere- 
brospinal meningitis, and various abscess formations, as of the liver or 
brain. 

The leucocytosis is very valuable in pneumonia, especially central, 
and that of children and drunkards. An ever-increasing number of 
cases of trichinosis are recognized by the eosinophilia alone; chronic 
poisoning with coal-tar products was recognized in a neighboring city, 
notwithstanding the violent denials of the patient and her husband; 
various tuberculous infections are thus differentiated; the secondary 
anaemias due to cancer, from primary anaemia. These are only a few 
illustrations of the more interesting uses of blood examination. 

For the surgeon, except as a differentiating diagnostician and for 
that he needs the blood report as much as the internist, the case is 
different. For him blood examination is almost synonymous with 
leucocyte counting. We can well appreciate the position of those 
men to whom blood-work is a novelty, who were successful surgeons 
before its day, who pride themselves that they do not need it and, 
indeed, are better off without it ; of the men who try to use it, have 
never studied it themselves but must depend on assistants to interpret 
results for them, and who complain of the times they have been de- 
ceived; they expect too much from it; and of those who were once 
the blood-counting assistants themselves, who believe and often make 
good their boast that they can guess from the patient's general 
condition what the count in his case is, and if another figure is re- 
ported demand its confirmation or are sceptical as to the assistant's 
skill. 

The question the surgeon usually demands of a leucocyte count is 
" Should I operate or not?" on a suspicious case of appendicitis, ty- 
phoid perforation, etc., and for this problem the count is half a point 
and the interpretation of it the other half. Almost never can the count 
decide the question alone. Some surgeons state they value it; more 
disregard it. The former never consider it as more than one of many 
symptoms, and very seldom as important an one as is the history, the 
physical examination, temperature, pulse, etc., but still of some help. 

In acute abdominal and pelvic cases, when the question is one of an 
immediate operation, leucocyte counts are not indispensable. A man 
who knows well the field uses the blood report when convenient, that 
is all. One confession of its inadequacy is the value claimed for the 
iodine reaction, etc. 

Both the medical man and the surgeon should remember that one 
count is seldom enough, any more than is one temperature determina- 
tion enough; it is the series that counts in diagnosis, just as it is in 



624 



CLINICAL DIAGNOSIS 



following a case awaiting operation. Unfortunately, blood examina- 
tion takes time; yet not as much as is sometimes thought. A good 
haemoglobin estimation can be made in from five to ten minutes, a 
leucocyte count in fifteen. 

For our American clinics the message is, less routine blood-work, 
but a better quality of that which is done. The examination of the fresh 
specimen will save a great many unnecessary routine counts. But 
when the blood examination is important, as it so often is in internal 
medicine, the work should be well done and repeatedly done ; well 
clone as regards technic, consideration of the condition of the part 
pricked, the hour of the last large meal, etc. ; repeatedly, until the 
curve is determined. 

MALARIA 

A few of the terms needing definition are the following: Schizogone, the 
asexual generation; gametoschizont, the sexual generation; schizont, or monont, 
a parasite of the asexual generation; merozoite, a segment (hyaline); gamete 
form, one of the sexual generation. Of the gamete forms, the macro game \c is the 
female cell; the micro gametocyte, the parent male cell; and microgamete the 
male cell, which is one " flagellum'' of the microgametocyte. S porogone, the cycle 
in the mosquito; vermiculu's, or ookinet, the motile fertilized macrogamete ; 
zygote, oocyst, sporoblast, are terms given to the spore cysts ; sporozoit, the young 
sexual form which develops in the sporoblast, and which, when inoculated into the 
blood, becomes a hyaline. 

By pigment is always meant the transformed haemoglobin, or "melanin," the 
brown granules of which are seen in the fresh specimen, never the chromatin 
granules. 

Hyaline always means a non-pigmented young form. A ring form is the shape 
which any young parasite may assume ; it is not a " kind " of organism. Preseg- 
menters are full-grown parasites the pigment of which has accumulated into 
masses and before segmentation appears. 

The examination of the fresh blood is easy and satisfactory. 
The forms can be more easily recognized in this way than in the 
stained specimens. On the other hand, they are more easily found in 
stained specimens, and when very few the Ross method should be used. 
While a diagnosis may be made without blood examination in typical 
cases, it never will be made without it in certain atypical, even per- 
nicious, cases without suggestive history or without fever, or with 
typhoidal temperature. 

The "Tertian" Organism; Hasmamceba vivax (Grassi); Plasmodium 
vivax (Plate IV). — This is the commonest form in Baltimore. Since 
the cycle extends over approximately forty-eight hours the paroxysms 
in the case of a single infection will occur on alternate days. The 
grouping is fairly definite, all the parasites undergoing their develop- 
ment quite in unison ; the paroxysms occur during segmentation, and 
last from twelve to fourteen hours. In the case of a double infection 
there will be a paroxysm each day, " quotidian" fever, and in the blood 
will be seen two groups. Three groups very rarely occur, but we have 
seen one or two cases. The tertian hyalines ( 1-4) do not modify their 



PLATE III. 



The Blood in Tertian Malaria. 

1. A hyaline form. 

2. A young tertian, perhaps twelve hours old, with beginning granulation. 

3, 4, 5, 6. Half grown, and slightly older, forms. 3 is a large cell containing two parasites. 
7. A form almost full grown. 
8,9. Full grown parasites showing division of the chromatin preceding that of the cell. 
10. A small tertian parasite in a red cell showing "stippling" (Plehn's granules), 
ii, 12, 13, 14. Gamete (sexual) forms. 13, in a cell with Plehn's granules. 

The Blood in Quartan Malaria. 

15. A very young quartan parasite. 

16. A full grown form with the chromatin still in one clump. 

17. A full grown form with the chromatin scattered. 

18. A segmenting parasite. 

The Blood in Aestivo-Autumnal Malaria. 

19. One field exactly reproduced from the blood of a case of pernicious malaria. 

20. Aestivo-Autumnal hyalines showing the projection of the chromatin masses from 

the cells. 

21. Blood platelets. 

22. Aestivo-Autumnal hyalines. 

23, 24. Red cells containing more than one hyaline. 

25. A full grown aestivo-autumnal parasite. 

26. Hyalines free in the plasma. 

27. A blood platelet lying on a red corpuscle. 
28, 29. Crescents. 




STAINED WITH HASTING'S MODIFICATION OF 
ROMANOWSKI'S STAIN. ALL DRAWN TO SAME SCALE. 



F. S. Lockvcood. 



THE BLOOD: MALAEIA 



625 



red blood-cell host either in size, color, or contour. The parasite is 
small, a little over 2 microns in diameter, colorless, non-pigmented, 
often disk-shaped, with an undulating periphery. It makes very 
rapid amoeboid movements and produces an extraordinary series of 
changes of shape and position. It also assumes the typical ring form 
once supposed to be characteristic of the sestivo-autumnal parasite. 
This ring is usually a little thicker at one point, hence the name " signet 
ring." In one cell may be one, two, or even five, such forms. In 
about twelve hours the corpuscle (6-7) will be a little larger, a little 
paler, but with a sharp, smooth, round margin. The organism is 
exceedingly amoeboid, the pseudopods often many in number, and so 
thread-like and pale that their connections can scarcely be seen; 
hence the cell may seem to contain a number of disconnected globules 
of pigmented protoplasm. The protoplasm is so little refractive that 
the outline of the parasite is difficult to make out. (It is thought by 
some that the parasite is more distinct and sluggish after the patient 
has began to take quinine.) The pigment has at this age appeared 
in moderate amount, and consists of very fine, light-brown granules, 
which dance with a motion so rapid that waves in the protoplasm 
must be assumed. The pigment is clustered especially at the ends of 
the pseudopods. The untrained eye, particularly of one who has not 
yet learned how to light the specimen well, will see merely a swollen 
pale corpuscle in which dance very fine pigment granules. At the end 
of twenty-four hours the cell (Plate IV, 8) is somewhat larger, paler, 
but still round in outline. The organism now fills about one-third 
of the cell. It is still quite amoeboid, but less actively so. The pig- 
ment has increased in amount, is a little darker, a little coarser, a little 
quieter, and is evenly distributed through the substance of the parasite. 
The nuclei of these forms can sometimes be seen in the fresh speci- 
men as a globular body at the end of a pseudopod, and especially in the 
degenerated extracellulars when spread out against other cells. 

During the last half of the cycle the growth is more rapid, and 
hence students often judge the age wrongly, considering size directly 
proportional to age. At forty hours the parasite (9) is full-grown. 
The cell is now about one and a half times the normal size. It is so pale 
that its outline will hardly be seen ; is, in reality, nothing but a shadow. 
The organism is from 8 to 10 microns in diameter, is round, and 
so little refractive that it is practically impossible to say where the 
parasite leaves off and the corpuscle begins. The pigment is more 
abundant and is evenly distributed throughout the parasite, an im- 
portant point in diagnosis, since in the quartan at this age it will be 
practically all in the periphery, and in the sestivo-autumnal at the 
centre. 

The next stage is the " presegmenter." The corpuscle is now 
40 



626 



CLINICAL. DIAGNOSIS 



almost or quite invisible. The pigment collects in one or more 
irregular clumps, the granules moving in irregular lines to form these 
masses. The organism is next a "segmenter" (10-17). The cor- 
puscle is no longer seen, the organism is slightly more opaque, denser, 
more refractive. Refractive dots appear irregularly in the body of the 
protoplasm, from 15 to 20 in number, crenations are seen at the 
margin, and lines of separation appear around these refractive dots 
marking off the future segments. The segments now become more 
sharply defined, until finally we have a clump of fifteen or twenty 
discrete circular masses with a refractive dot in the centre. The clump 
may be irregular or form two quite concentric circles. The pigment is 
merely left in masses between these segments. The segmenter now 
seems to burst, and the young organisms spring apart. Each segment 
is a hyaline, and is ready for a new cell as host. 

The whole cycle may occur in the peripheral blood, but the number 
of segmenters found will not be as large as would be supposed from 
the number of parasites seen a few hours previously, since so many 
of them have accumulated in the internal organs. A few hours after 
the first segment appears the chill begins. 

The above is a description of a typical tertian parasite. One finds, however, 
some variations in this group. In one rare form, a few cases of which we meet with 
each year, the parasite forms more pigment than usual and in large coarse granules, 
but of a lighter brown color than those of the quartan or the adult sestivo-autumnal, 
and which form dense clusters at the ends of the pseudopods, so filling them that 
the granules cannot dance at all. The fine thread-like pseudopods stand out with 
great distinctness. The cell containing it is often not swollen but very pale, yet in 
one such case all the full-grown forms found were in cells from 8.5 to 13.3 microns 
in diameter. 

Pigmented leucocytes are common (perhaps since the pigment granules are 
conspicuous). 

The grouping does not seem to be so definite, and hence the chills are slightly 
longer than usual. 

Extracellular Tertian Forms. — These are of two varieties, the 
degeneration forms and the gametocytes. The degeneration forms, or 
the extruded intracellulars (18-21), may in a short time after the 
specimen is made be the only ones seen. These are parasites which 
have burst from their cells and died. The organism is often seen to 
" run out" as if through a very fine hole. If it entirely escapes the 
haemoglobin leaves the cell through the same opening, and only a 
shadow is left, but very often it does not, and hence we have the dumb- 
bell-shaped form with the constriction at the orifice. After the parasite 
is free in the plasma the pigment will for a time be extremely active 
in movement and then gradually become quiet, as the organism dies 
and then degenerates. It may break up into fragments, forming a 
string of four or five small pigmented spherical masses (20, 21), or 



THE BLOOD: MALAEIA 



627 



it may become deformed or swollen and vacuolated, the so-called 
" sporulating forms" which much resemble reproduction forms (23, 
24). 

The more interesting extracellulars (but stained specimens show 
that these are surrounded by the shell of a corpuscle) are the gameto- 
cytes, which correspond to the crescents of the sestivo-autumnal form, 
but have a less distinctive shape. Like them they can be found at all 
times in the blood after a few days of the infection. The macrogamete 
was formerly considered a cadaveric form, and was known as a 
" swollen extracellular." They are large organisms, pale and indis- 
tinct, some three or four times the size of a red blood-cell. In some no 
trace of a corpuscle can be seen, the pigment is abundant, in very coarse 
rods, and in very active movement. The nucleus is about 3.5 microns 
in diameter, and is often evident in the fresh specimen; either its 
outline can be seen, or its size and shape may be recognized since it is 
the only portion of the parasite which is not invaded by the pigment 
granules. The extreme vitality of these cells is astonishing, as might 
be expected from the fact that it is their function to continue the life 
of the organism in the mosquito. Recently one with particularly active 
granules was left by a student under his microscope in a moderately 
warm room. Eighteen hours later the pigment w r as still actively 
dancing. Whether these very large forms with such active pigment and 
quite unlike those in the stained specimens we call macrogamete forms, 
are the same or are fertilized forms, I do not know. The microgameto- 
cytes, smaller than the former, are from 8 to 10 microns in diam- 
eter. The pigment is in active motion, but soon forms a circle around 
the centre and becomes stationary. As a rule, nothing more happens. 
But the pigment, instead of collecting, may become even more active, 
as if stirred up by something moving within the cell. The margin may 
undulate, and the flagella, four or five in number, burst out. These 
flagella are the microgametes or male elements. Although the name 
" flagellum " is still used, it should be borne in mind that it is decidedly 
a misnomer. They are threads whose length is from two to three 
times the diameter of a red blood-cell. Sometimes these threads are 
rendered irregular by fusiform masses of protoplasm often containing 
pigment granules. These make them more conspicuous and much 
easier to follow when they break loose, and wander for more than 
an hour through the field. After the flagella have broken loose a 
small cell, with its pigment near the centre, is all that remains. This 
process of flagellation is not seen in the very fresh specimen, but 
occurs in from fifteen to twenty minutes after the blood has been 
drawn, proof that it does not occur in the body, but under the stimulus 
probably of the lowered temperature. 

Quartan Malaria. Haemamoeba malariae( Plate IV). — Of this rare form 



628 



CLINICAL DIAGNOSIS 



we see but one or two cases a year. The cycle of development requires 
seventy-two hours, hence if but one group is present the paroxysms 
will occur on each fourth clay; if two groups, there will be two days 
with paroxysms, and then one free day, followed by two more par- 
oxysms; if three, quotidian fever, providing each group is large 
enough numerically to cause a chill. The grouping of this parasite is 
even more uniform than that of the tertian, the forms being nearer of 
the same age, and hence the paroxysms are slightly shorter, often re- 
quiring but ten hours. 

The hyalines (26) cannot be distinguished from the tertian, but 
may be a little later when the pigment first appears (27), since the 
granules are coarser, blacker, and less actively vibratory. As the para- 
site grows the corpuscle becomes slightly smaller and shrunken, and 
with an irregular crenated margin; but much deformity is rare. The 
protoplasm of the parasite is more refractive than of the tertian, even 
looks waxy, hence the outline of the pseudopods is easily seen. The 
parasite is definitely amoeboid, but not actively so. 

In twenty-four hours the cell is smaller, crenated, and brassy in 
color. The organism is round or oval, sometimes slightly amoeboid, 
but very sluggishly so. It is very distinct, since refractive. The pig- 
ment is coarse, blackish-brown in color, gathered at the periphery, 
especially on one side. At this age all motion of the pigment granules 
has practically ceased. The parasite soon fills from one-third to one- 
half of the cell (30, 31), becomes rounder, and is non-amoeboid. The 
cell may be shrunken, crenated, and brassy, although some may not 
seem in the least altered. The pigment is coarse, much blacker than 
the tertian, motionless, and entirely at the periphery. The protoplasm 
is very distinct, refractive, and waxy in appearance. 

During the third day only a rim of the cell is left, and this is usually 
of a dark, brassy color. The organism (32-34) is now full-grown and 
about 7 microns in diameter, the figure usually given. 

We have measured a good many quartan parasites, and, contrary to this, find 
that of 135 full grown and segmenters, 60 per cent, were from 7.4 to 8.1 microns 
in diameter, and only 18 per cent, small, from 6.2 to 7 microns. Of those two- 
thirds grown, 43 per cent, were in cells from 6.2 to 7 microns in diameter, the rest 
in cells of normal size. 

At sixty hours the cell can hardly be seen. The organism is round 
or elliptical and motionless (35). The cqarse dark pigment is all at 
the periphery. 

The pigment now flows to the centre in definite streams along 
radial channels, thus giving a beautiful wheel-like picture (36), the 
rows of pigment granules forming the spokes. The granules finally 
collect in a clump at the centre. These are the presegmenters. The seg- 



PLATE IV. 



The Parasite of Tertian Fever. (Drawn by Mr. Brodel for Thayer and Hewetson's paper, 
The Malarial Fevers of Baltimore, Johns Hopkins Hospital Reports, Volume V. We copy 
the original legend.) 

i. Normal red corpuscle. 
2, 3, 4. Young hyaline forms. In 4, a corpuscle contains three distinct parasites. 
5, 21. Beginning of pigmentation. The parasite was observed to form a true ring by the con- 
fluence of two pseudopodia. During observation the body burst from the corpuscle, 
which became decolorized and disappeared from view. The parasite became, almost 
immediately, deformed and motionless, as shown in Fig. 21. 
6, 7, 8. Partly developed pigmented forms. 

9. Full grown body. 
10—14. Segmenting bodies. 

15. Form simulating a segmenting body. The significance of these forms, several of which 
have been observed, is not clear to the writers, who have never met with similar 
bodies in stained specimens so as to be able to study the structure of the individual 
segments. 
16, 17. Precocious segmentation. 
18, 19, 20. Large swollen and fragmenting extra-cellular bodies. 
22. Flagellate body. 
23, 24. Vacuolization. 

The Parasite of Quartan Fever. 

25. Normal red corpuscle. 

26. Young hyaline form. 

27-34. Gradual development of the intra-corpuscular bodies. 

35. Full grown body. The substance of the red corpuscle is no more visible in the fresh 
specimen. 
36-39. Segmenting bodies. , 

40. Large swollen extra-cellular forms. 

41. Flagellate body. 

42. Vacuolization. 



V * 9 



"5 



The Parasi 1 



an Fever. 



PLATE IV. 




4Rm 




Engraving by E.Alunke,Lipsi 



THE BLOOD: MALARIA 



629 



menters are among the most beautiful things seen under the micro- 
scope. The organism becomes opaque and very waxy ; refractive dots 
appear in a single regular circle around the periphery; crenations of 
the border appear with these dots as their centre; lines of division 
start from these and run to the centre, forming from six to twelve 
rays like the petals of a flower, hence the names " daisy," " mar- 
guerite," or "rosette" form (37, 38). These segments then separate 
as in the tertian. The whole cycle of the quartan occurs in the periph- 
eral blood, hence one finds about as many segmenters as the number 
of the full-grown parasites would lead one to expect. 

The gamete forms (40, 41) are very seldom seen. They are sim- 
ilar but somewhat smaller than the tertian. Flagellation occurs in the 
same way. The extracellular degenerate forms are found, although 
the parasite keeps in the cell much better than does the tertian. 

In review, the differences between the tertian and the quartan may 
be stated as follows : The cycle of the quartan is seventy-two instead of 
forty-eight hours. This organism is, throughout its entire history, 
smaller, more refractive, less amoeboid, its pigment is coarser, blacker, 
less vibratory than the tertian, and keeps a peripheral position. The 
corpuscle is shrunken, crenated, and brassy. The presegmenter and 
segmenter forms of the quartan are perfectly distinctive, since they 
have such geometrically regular forms. The number of the segments 
is small, from 6 to 12; and, lastly, more of the segmenting forms are 
found in the peripheral blood. 

iEstivo-autumnal. Plasmodium praecox. Haematozoon falciparium ( Plate 
V). — This is a common form, particularly in the Tropics, and the most 
dangerous of the three. In the fresh infection the grouping is quite 
definite, but soon the members of a group lose their unison, and hence 
are found in the internal organs of all ages at once. For this reason 
what was first an intermittent fever becomes more and more con- 
tinuous, until finally the temperature may resemble that of typhoid 
fever. The duration of the cycle is rather uncertain. Dr. Thayer con- 
siders that while usually of about forty-eight hours, it may vary from 
twenty-four to perhaps seventy-two. 

All students, it is said, "pass through the stage" of dividing this form into 
"benign," "malignant," "pigmented," " non-pigmented," etc., varieties, but most 
recover, especially those who follow the splenic blood carefully. Some separate 
it into the " malignant quotidian" and the " malignant tertian," the latter sim- 
ilar in form to the "benign tertian" (ordinary tertian), except smaller, from one- 
third to one-half the size of red cells, and with from 8 to 12 segments. The: 
" malignant quotidian" is from one-third to one-fifth the size of red cells, " often;, 
unpigmented" and with from 6 to 8 spores. In this locality we are often struck; 
by the great difference in the ajstivo-autumnal parasites, both clinically and mor- 
phologically, especially as regards the amount of pigment and the presence in the 
circulation of the adult much-pigmented forms, but Dr. Thayer thinks such division 
not justified as yet. 



630 



CLINICAL DIAGNOSIS 



The hyalines are similar to those of the tertian and the quartan, 
perhaps are slightly smaller, but they assume the signet-ring form 
much more commonly and hold it longer. Then they are very re- 
fractive, hence easily seen, but may at any time lose this refractivity 
and become amoeboid exactly as does the tertian. In a severe infection 
even five rings may occupy one cell. 

As the parasite (7-12) grows a very slight amount, usually but 
one or two granules, of pigment appears. These are so fine that they 
are easily overlooked. These are motionless as a rule, although some- 
times slightly dancing, and are seen at the periphery of the parasite or 
at the inner edge of the biconcavity. The cell is commonly very much 
injured, shrunken, crenated, and brassy, even when the parasite is very 
young, and yet some infected cells look normal. A great many 
cells which contain no parasite also show these same evidences of 
being poisoned. The parasite at this stage fills about one-fifth 
of the cell. As a rule the infected cells now disappear from 
the periphereal circulation, perhaps since the injured cells are 
treated *as foreign bodies, hence are filtered out, and to study their 
further development the spleen must be punctured. The suddenness 
of their departure is quite surprising, as well as exasperating to a 
demonstrator, since in two hours a large brood may disappear. Hence 
it is that if no crescents are present the diagnosis will be uncertain 
unless repeated examinations of the blood are made. In some cases, 
however, all ages of this parasite may be found in the peripheral blood. 
In these cases and in the blood obtained by splenic puncture, the pig- 
ment is seen to increase considerably in amount, and to be in rather 
coarse, dark granules, or remains scanty', while in some scarcely any 
seems to form. Those parasites with much coarse black pigment it is 
impossible to tell from quartan forms, and this mistake is frequently 
made. The more malignant the parasite the fewer older forms are 
seen in the peripheral blood, and according to some the less pigment 
is formed ; the pernicious cases always have abundant young parasites 
in the peripheral blood. In some cases the haemoglobin seems to 
gather around the parasite, leaving an almost colorless ring at the 
periphery of the red cell (13). In the internal organs the whole cycle 
seems to occur inside of large macrophages. The parasite grows to 
about one-half the size of the cell (5 microns). When full-grown 
the pigment is all in the centre (15-20), never diffusely scattered, and 
never peripheral. The protoplasm is waxy. This form is very char- 
acteristic. Although rarely seen in the circulation, in two cases 
recently during the class demonstration we found several beautiful 
full-grown and one segmenting form (see Fig. 93). The segmen- 
ted vary in size from 2.5 to 5 microns in diameter. The process 
of segmentation (21-24) is similar to that of the tertian, the waxy 



PLATE V. 



The Parasite of Aestivo-Autumnal Fever. (Drawn by Mr. Brodel for Thayer and Hewetson's 
paper, The Malarial Fevers of Baltimore, Johns Hopkins Hospital Reports, Vol. V. We copy 
the original legend.) 

1,2. Small refractive ring-like bodies. 
3-6. Larger disc-like and amoeboid forms. 

7. Ring-like body with a few pigment granules in a brassy, shrunken corpuscle. 
8, 9, 10, 12. Similar pigmented bodies. 

11. Amoeboid body with pigment. 

13. Body with a central clump of pigment in a corpuscle, showing a retraction of the 
haemoglobin-containing substance about the parasite. 
14-20. Larger bodies with central pigment clumps or blocks. 

21-24. Segmenting bodies from the spleen. Figs. 21-23 represent one body where the entire 
process of segmentation was observed. The segments, eighteen in number, were 
accurately counted before separation as in Fig. 23. The sudden separation of the 
segments, occurring as though some retaining membrane were ruptured, was 
observed. 

25-33- Crescents and ovoid bodies. Figs. 30 and 31 represent one body which was seen to 

extrude slowly and, later, to withdraw two rounded protrusions. 
34, 35. Round bodies. 

36. " Gemmation, " fragmentation. 

37. Vacuolization of a crescent. 

38-40. Flagellation. The figures represent one organism. The blood was taken from the 
ear at 4.15 p.m.; at 4.17 the body was as represented in Fig. 38. At 4.27 the flageila 
appeared; at 4.33 two of the flageila had already broken away from the mother 
body. 

41-45. Phagocytosis. Traced by Dr. Oppenheimer with the camera lucida. 



PLATE V. 




THE BLOOD : MALAEIA 



631 



opaque organism breaking up irregularly into fifteen or sixteen very 
small segments. Very few degenerated extracellulars are found. 

Crescents and Ovoids. — These very characteristic forms of the 
sestivo-autumnal parasite are found in the internal organs from about 
the fifth clay of a fresh infection, and appear in the peripheral blood 
on about the seventh day. The crescents (29) are slightly longer 
than the red blood-cells, sometimes of a beautiful crescentic shape with 
rounded ends; others are somewhat irregular. They are very refrac- 
tive, with a double contour, and usually present a fringe of the degen- 
erated red blood-cell which in the concavity is somewhat more abun- 
dant and forms the so-called " bib." The pigment is considerable in 
amount, clustered at the centre of the crescent either as a confused 
mass, a sheaf, or a ring. The granules are coarse and usually rod- 
shaped. While watching the parasite it may lose its crescentic shape 
and become first oval (ovoids, 30-33), then circular (34-36), or it 
may resume the crescentic shape. Around the circular there is no 
trace of the corpuscle left ; its protoplasm is much less refractive than 
the crescent. Two forms of the circulars have been described in the 
fresh blood, the macrogamete and the microgametocyte ( see page 636). 
The former may flagellate. Fertilization has been watched by several 
observers, first of all by MacCallum 98 and then by others of this hos- 
pital, and more recently by Moore, et al." Vacuolation and fragmen- 
tation of these sexual forms are not rare (Plate V, 37). 

The phagocytes are well studied in this form of malaria; in fact, 
pigmented leucocytes are as valuable in diagnosis as is the parasite 
itself. These are large mononuclears especially, polymorphonuclear 
neutrophiles, and macrophages (see page 593, and Fig. 93). Pig- 
mented macrophages are seen only in severe cases. In these phago- 
cytic cells are found free pigment granules, or masses of pigment, or 
parasites, especially segmenters and flagellates. In the tertian and 
quartan they occur just after a chill, but in the sestivo-autumnal at 
any time. The large macrophages especially contain organisms, even 
those within cells. Some of these macrophages are necrotic. 

The malarial pigment is black, " melanin," and iron cannot be 
demonstrated in it. 

The Cycle within the Mosquito. — This cycle has been followed by several 
observers in the case of Plasmodium prsecox. The crescents in the blood in the 
stomach of the mosquito become circular forms. The male circulars flagellate 
in the same way as on the stage of the microscope, and probably in response to 
the same stimulus, the lowering of temperature. The flagella then fertilize 
the female circulars. This occurs in from 1 to 1.5 hours after the mosquito has 
bitten. During the flagellation of the microgametocyte the macrogamete ripens 
by casting off karyosomes, polar bodies consisting of chromatin, and projects a 

98 Johns Hopkins Hosp. Bull., November, 1897. 
"Johns Hopkins Hosp. Bull., October, 1902. 



632 



CLINICAL DIAGNOSIS 



slight mound, through which the free flagellum has been seen to enter. The 
nuclear material of the macrogamete and the microgamete then unite. The cell 
remains naked and assumes a motile spindle form called the " vermiculus." Its 
size varies from 20 microns up, and is to be found in from forty to forty-eight hours 
after the blood has been ingested. This motile form in the case of malaria has 
been found only in the contents of the mosquito's stomach. This vermiculus 




Fig. 116. — Various stages of the development of Plasmodium praecox in the mosquito's stomach. 
a, In four to four and a half days after the bite ; b, c, five to six days ; d, eight days (Plasmodium vivax). 
(From Braun.) 

actively bores its way through the epithelial cells of the intestinal wall, and becomes 
encysted between the intestinal epithelium and the elastic layer, the " tunica elastico- 
muscularis," which forms the membrane of the oocyst. This oocyst now increases 
in size. The nucleus divides rapidly. As the cyst grows it bulges outward from 
the intestinal wall, forming a pendulous tumor into the body cavity (see Fig. 117). 
These vary from 4.5 to 30, or even 60, and as high as 90 microns in diameter. This 




Fig. 117. — The intestine of an infected mosquito with oocysts attached. (From Braun.) 

stage is called the " medium zygote," or the " medium sporoblast," and is con- 
spicuous because of the amount of pigment. There may be 200 such tumors at- 
tached to the intestine of the mosquito. The protoplasm now gathers around the 
divided nuclei (Fig. 116, a), a process analogous to the sporoblast formation of 
the coccydia except that here the separation is less perfect, the daughter cysts 
being connected by bridges of protoplasm. It is now known as a " large zygote" 



THE BLOOD: MALARIA 



633 



or a " large sporoblast." In each of these divisions the nucleus divides into great 
numbers (b, c), the daughter nuclei remaining on the surface of the various 
daughter cysts. The protoplasm collects around each, first forming spherical cells, 
which then elongate into threads lying parallel in masses over the residue of the 
sporoblasts. These threads are called " sporozoits." Their nucleus also becomes 
elongated. The final length of these sporozoits is about 14 microns, and the width 
about 1 micron. Their protoplasm is thick, homogeneous, and very refractive. 
All sporozoits of one oocyst ripen at about the same time ; they may be present 
even to the number of 10,000 in some oocysts, while others contain but a few 
hundreds. When ripe the oocyst bursts into the body cavity, the sporozoits wander 
free, but, as if directed by some positive chemotactic influence, finally collect in 
the salivary glands. They are motile, moving by a bending gliding movement. 
Inoculated by the mosquito's bite into the blood-vessel of man, they attach them- 
selves to and finally penetrate into the red blood-cells, a process actually observed 
by Schaudinn. They are said to stay for some time on the surface of the cell 
before penetrating, and it is said that if quinine is now given they will drop off 
from the corpuscle. This may explain the opinion of several recent writers who 
insist that the hyaline and older forms are always on and not within the cor- 
puscle. As a rule the first chill will come on about the eighth or twelfth day 
after the mosquito bite, although, of course, it will depend on the number and the 




Fig. 1 18.— Attitude of mosquitoes on wall, a, Anopheles ; b, Culex. 

virulence of the parasites introduced into the circulation. Since some mosquitoes 
contain fully 200 of these oocysts (of course not all of the same age), and some of 
these contain 10.000 or more sporozoits, the number of the hyalines injected by 
one bite may be considerable. 

For the tertian the optimum temperature for this cycle is 28 0 to 30 0 C, and 
the time eight days ; below 17° to 20 0 C. there is no development. The quartan 
form can develop at a slightly lower temperature. 

The Anopheles group of mosquitoes is the only one as yet shown to be the 
host of the malarial organism. For a full description of these insects the reader 
is referred to various books. 100 

The Anopheles genus may easily be recognized by its attitude on a wall, since 
(see Fig. 118, a) its body is in a straight line with head and proboscis, and at an 
angle with the wall, the " awl shape," while Culex (b) sits " hunch-backed," its body 
parallel to the wall, its proboscis at an angle of forty-five degrees with its 
body. The genera are separated by the relative length of their probosces and 
palpi (see Fig. 119). Of the Anopheles female these are of equal length and 
scaled, while of the Culex, Stegomyia, and Tsemiorhyncus females the palpi are 
short and insignificant. It is only the female Anopheles which bites. The wings 

100 Stevens and Christophers, " Malaria of the Tropics," 1905 ; Nuttall and 
Shipley, Jour, of Hygiene, vol. i., Nos. 1 and 4; vol. iii., No. 2. 



634 



CLINICAL DIAGNOSIS 



of Anopheles alone are spotted, as a rule. Anopheles usually holds its hind pair 
of legs stretched out and oscillating in the air. 

Its egg and larva are characteristic : the former, from its boat-like shape and 
lateral air-cell floats; the latter, from its attitude in the water, lying parallel with 
and just below the surface. 

Stained Specimens. — The technique is fairly simple. Very thin 
smears must be made (see page 452) ; these are stained by any one 
of the various polychrome methylene blue-eosin mixtures (see page 
459)- The fresher the smear when stained the better the preparation. 

Ross has recently described a method which is of the greatest 
value when only a few parasites are present. A very thick drop of 
blood is placed on the slide and spread over an area equal in size to 
a ten-cent piece. It is then dried thoroughly in the air. The slide is 
then covered with water in order to remove the haemoglobin. Care 
should be taken that the washing be not too vigorous, else the fresh 



blood which has not been fixed will be washed off. The specimen is 
then stained in the usual manner. In such a specimen parasites appear 
numerous, when in ordinary smears scarcely one is found. 

Tertian (Plate III, 1— 14). — The youngest hyalines consist of a 
mass of blue protoplasm and a clump of carmine-violet stained chro- 
matin. They are 2 to 3 microns in diameter. Soon the " achromatic 
zone" appears, the " vesicular part" of the nucleus, which may be 
the largest part of the parasite. The protoplasm now often forms a 
wide crescentic ring surrounding this, with the chromatin mass be- 
tween the tips of its horns, but often not quite touched by them. A 
" milk-white zone" of Gautier often surrounds the chromatin mass, 
but is not present at all ages, nor in all of the same age. To just 
what part of this structure the term nucleus shall be applied is dis- 
puted. Stephens and Christophers, as well as many previous ob- 
servers, use the term for the chromatin mass alone, while others in- 
clude the chromatin mass and milk-white zone, and others also the 
much larger achromatic zone. 





Fig. 119. — Heads of mosquitoes, a, Culex; b, Anopheles. 



THE BLOOD: MALARIA 



635 



At this point should be emphasized the necessity of seeing dis- 
tinctly the blue protoplasm and the red chromatin to recognize the 
malarial hyaline. This is necessary, since so many other structures 
can look almost like a hyaline, as, for instance, certain degenerations 
of the red blood-cells, and particularly platelets on the cells ( Plate III, 
21, 27). These or any other structure on the cell are always sur- 
rounded by a colorless zone, probably due to the pressure which they 
exert on the corpuscle, squeezing the haemoglobin from their vicinity. 
It is of interest that in the case of malarial parasites this is not usually 
the case, but the haemoglobin is in direct contact with the parasite, 
good evidence, says Ross, that the hyaline is intracellular and not 
adherent to the surface of the cell. (Argutinsky, Stephens and Chris- 
tophers, and others.) 

At the end of twenty-four hours there has been an increase in 
the amount of protoplasm, the achromatic zone is a little larger, but 
the chromatin is the same in amount, although now in a more irreg- 
ular nodular mass. The milk-white zone is seen in some. Some forms 
have two or more such definite nuclei. 101 The nucleus of this parasite 
is not perfectly specialized but is rudimentary, the nuclear material 
being scattered in the cell or collected in one or more masses. In the 
full-grown the chromatin breaks up into a cluster of fine granules 
occupying a large achromatic zone, both of which just before seg- 
mentation seem entirely to disappear. It then reappears in fine gran- 
ules arranged in strands and masses throughout the protoplasm. These 
congregate into four or five clusters and then separate into from fifteen 
to twenty dense round masses. Achromatic zones now appear around 
each of these masses, the protoplasm collects around them as a centre, 
and the segments separate. For a description with much more com- 
plex details, which tries to bring this division into the same class as all 
nuclear division, see Argutinsky. 102 The pigment at the beginning 
of segmentation is pushed to the periphery, and after segmentation 
is complete, collects in one or two masses near the centre. It will be 
remembered that in the fresh specimen at the time the pigment went 
to the centre there was no evidence of the separation into segments, 
hence segmentation is a process which is really complete before there 
is any sign of it in the fresh specimen. It is claimed by many that 
in the stained specimen the gamete generation can be followed from 
the hyaline form onward. According to Stephens and Christophers 
the young gamete is characterized by the position of the chromatin, 
which lies in the centre of the vacuole instead of at the edge 
as is the rule in the asexual forms. During the cycle the cell is in 

101 For evidence of conjugation, see Ewing, J. H. H. Bull., 1900, and Clinical 
Pathology of the Blood, 1903. 

102 Arch. f. mikr. Anat. und Entwicklungsges, 1901, Bd. 59, p. 315. 



636 



CLINICAL DIAGNOSIS 



some cases filled with basophile granules (see page 480), " Plehn's 
karyochromatophilic granules," " Schiigner's granules" (Plate III, 
10, 13). Bignami and Bastianelli claim that the division of chromatin 
into fine granules marks the gamete even in the hyaline stage, but 
Lazear doubts this, since the pigment always just before segmentation 
divides into fine granules. 

The full-grown macrogamete (Plate III, 14) contains an abun- 
dance of protoplasm which stains a deep blue, and a small amount of 
chromatin in a compact mass which is peripherally placed and sur- 
rounded by a thin vacuole-like area, this nucleus occupying about one- 
tenth the cell. The pigment is uniformly distributed. The remains 
of the corpuscle often cannot be seen. In the microgametocytes ( Plate 
III, 11) the chromatin is more voluminous, looser, centrally placed 
in a large achromatic zone. It is in a band arranged as a knot or 
skein, its thread-like nature always evident. The parasite fills about 
two-thirds of the cell ; its protoplasm is in a ring around the nucleus. 
It stains a grayish-green or grayish-red color, and not at all the blue 
of the female form, hence the pigment is easily seen. 

Quartan (Plate III, 15-18). — The structure of the quartan re- 
sembles that of the tertian, but in the hyaline the chromatin mass is 
less dense, is, in fact, an irregular clump of granules, and in the older 
forms is in a cluster of fine granules without a distinct achromatic 
zone, hence often hard and sometimes impossible to see. The parasite is 
usually a band across the cell. 

iEsnvo-AUTUMNAL (Plate III, 19-29). — In the hyalines the chro- 
matin is in from one to three masses or filaments. The protoplasm is 
scantier than in the other forms and remains so throughout the cycle. 
Characteristic of this form at a later stage is the large oval ring of pro- 
toplasm with a thicker layer opposite the chromatin mass. The young 
gamete forms are characteristic (Maurer). They are accurately spher- 
ical, being a ring of the same thickness all the way around. The nu- 
cleus forms a portion of the ring, but this does not project as in the 
schizonts, and the red blood-cell usually presents no coarse stippling 
(Maurer). Of the crescents, the male form has its chromatin in a 
loose net-work which occupies the most of the cell, comparatively 
little blue staining protoplasm, and the pigment scattered throughout 
its body. This crescent is somewhat kidney-shaped, is shorter and 
broader than is the female form. The female crescent is quite long 
and narrow, its chromatin is more compact and more or less centrally 
placed, there is much more blue staining protoplasm, and the pigment 
is in a ring around the nucleus or in a clump near the centre. 

There are also two types of circular bodies, the microgametocyte, 
smaller than the red, perfectly spherical, with chromatin in the cen- 
tre in a large irregular mass like a tangled thread, later in four or 



THE BLOOD: MALAEIA 



637 



five dense masses near the periphery, which then are extruded as the 
flagella (or microgametes) . Sometimes a thin bluish envelope of 
protoplasm can be stained enveloping the chromatin thread of the 
rlagellum. The macrogamete is two or three times as large as this, 
often of triangular shape, with abundant blue protoplasm ; the chroma- 
tin is in a single mass at the periphery and surrounded by a circle of 
pigment. In the stained specimens (especially in sections cut in par- 
affin) can be seen the projection of the chromatin mass and part of the 
protoplasm apparently from the surface of the cell, hence the belief 
(Argutinsky, Stephens and Christophers) that it at all stages rests on 
the cell, not in it (Plate III, 20). Study of the fresh blood, by far the 
more important, noting especially the way they burst through a fine 
opening, their amoeboid phenomena, etc., shows conclusively, we think, 
that they are intracellular. 

The following points may be emphasized: In the case of tertian and quartan 
malaria, organisms and chills are not synonymous. The infection must reach a 
certain degree (250,000,000 organisms, Ross) before chills begin. Because no para- 
sites are found may not rule out malaria, especially if the patient has been taking 
quinine. Fevers with long intervals are thus explained, very many parasites being 
killed off at each chill, hence some delay before enough have reaccumulated to 
cause a second chill. 

In a case of fever to find a few crescents does not mean necessarily that the 
fever is malaria, since these gamete forms may persist for months after the asexual 
cycle has stopped. In case hyalines also are found the diagnosis is justifiable, 
especially if the fever yields promptly to quinine. The asexual cycle is the " feb- 
rile cycle." The sexual has no influence over this host, except that it may again 
start up the asexual cycle, explaining relapses in early spring and especially those 
occurring after an accident or a surgical operation even two years after any 
chance of reinfection has passed. Not all the members of the same tertian or 
quartan group are of exactly the same size or age, and the segmentation continues 
through at least twelve or fourteen hours. This is fortunate, since, did they seg- 
ment more in unison, hemoglobinuria would probably be more common (as anal- 
ogue, see Texas fever of cattle). The size of the segmenters varies so much that 
it is supposed that when the majority begin to segment all the others not quite 
mature as yet are drawn into a "precocious segmentation" (Plate IV, 16, 17). This 
keeps the groups at an almost equal age, for otherwise these younger forms would 
disturb the grouping to the degree which occurs in sestivo-autumnal malaria. It 
also may explain the sudden appearance of a second group in a previously single 
infection, a few of the forms being so young that they cannot be drawn into 
this precocious segmentation. 

The conditions on a slide under the microscope are more like those in the mos- 
quito's stomach than in the circulating blood, hence many changes (e.g., flagella- 
tion, the cadaveric forms) must not be considered as occurring in the human 
host. 

There is a remarkable periodicity in the cycle which we do not understand ; 
among other illustrations, the tendency to flagellate. In some cases used for 
class demonstration so many flagellated forms will be found that all the students 
can study the process ; in other cases with even more sexual forms not one will 
flagellate. 

The distribution of parasites in the body is remarkable. The aestivo-au- 
tumnal lives for the most part in the spleen, liver, and bone marrow ; the same to 
a less degree is true of the tertian. But it is their accumulation in other organs 
which is important; in the brain and medulla causing thrombi, hence paralyses, 



638 



CLINICAL DIAGNOSIS 



transient aphasias, mental symptoms, even sudden death ; and in the mucosa of 
the gastro-intestinal tract causing even necrosis and sloughing, hence severe 
vomiting and diarrhoea. 

Whether the virulence of the infection depends on the number of parasites 
or not is hard to answer ; it certainly does not on the number in the peripheral 
blood, although pernicious cases have usually many organisms visible. 

Trypanosomiasis. — This most interesting disease in man (" sleep- 
ing sickness"), which has recently attracted so much attention, is now 
considered clue to an actively motile fish-shaped flagellate, Trypan- 
osoma gambiense (Plate II, 21), which can be seen in the blood- 
plasma, moving with a screw-like motion among the red blood-cells 
which it scarcely disturbs. It is from two to three times as long as 
a red blood-corpuscle (18 to 25 microns long, 2 to 2.5 microns wide), 
with one flagellum anteriorly and an undulating membrane which ex- 
tends the whole length. 

The parasite is to be searched for in the fresh blood specimens 
with a medium magnification. There are present sometimes many, 
generally few. They vary much in numbers, often being absent for 
long periods, even a month or more, and then reappearing in force, 
even 70 to a cover-slip specimen. The symptoms seem to bear no rela- 
tion to the number of parasites in the peripheral blood ; it may be nec- 
essary to centrifugalize to find any. They can most surely be found by 
puncturing the cervical lymph glands, and are easy to find in the 
fluid of cedematous areas. Inoculation experiments may be necessary. 
Stained with a polychrome-methylene blue and eosin mixture they 
have a rather large red nucleus at about the middle, a centrosome stain- 
ing intensely in a vacuole-like area very near the blunt posterior end, 
and a red line of chromatin running down the edge of the undulating 
membrane and terminating in the red flagellum. The protoplasm of 
the body takes a blue stain. Various involution forms will, of course, 
soon be seen in a fresh specimen. The parasite contains no pigment 
and hence must live on the plasma. It multiplies by longitudinal 
fission. 

For a long time it has been well recognized that this organism was 
a common and harmless parasite in the blood of fish, amphibians, 
birds, and rats, and an important cause of disease among horses, cat- 
tle, and other domesticated animals in India, Africa especially, and 
South America. The disease has borne several names. The " tsetse fly 
disease" of Central Africa caused by Trypanosoma brucei, is usually 
fatal to almost all domestic animals, especially the horse, the mule, and 
the dog, less so for cattle and still less so for the ass, least for sheep and 
goats. Man was, however, supposed to be immune. It is communi- 
cated by a fly, Glossina morsitans. Flies seem to carry it mechani- 
cally, and to play no part in its life history. 

The " surra," of India, a disease which attacks horses and camels 



THE BLOOD: TRYPANOSOMIASIS 



G39 



especially, is caused by a parasite discovered in 1881 by Evans, which 
differs in no way from Trypanosoma brucei. The same may per- 
haps be true of the parasite of kk mal de Caderas" of Central and 
South America, which attacks especially horses. 

The parasite was first discovered in man by Dutton in 1902 in 
the blood, and in the cerebrospinal fluid of a case of sleeping sickness 
by Castellani, but it was Bruce who first recognized its pathogenic im- 
portance in man. This disease is communicated by Glossina palpalis. 

Of eighty persons in good health in Uganda, Bruce found the 
parasite in the blood of twenty-three, but many of these have since 
died. The parasite may thus be found in men apparently normal for 
some time, but the present opinion is that it is sooner or later fatal. The 
symptoms are somewhat like those of malaria. It is a disease which 
can take a rather acute course, but as a rule is exceedingly chronic, run- 
ning for years, yet uniformly fatal when the parasite invades the 
cerebrospinal fluid which seems to be the common or perhaps unfail- 
ing result. It is accompanied by an irregular temperature often with 
intermissions, by multiple erythema, moderate anaemia, marked 
emaciation, loss of strength, localized cedema of face, trunk, and legs, 
enlarged spleen, and swelling of the lymph-glands, especially those of 
the posterior cervical region. Later, the so-called " sleeping sickness" 
begins, which is due to the presence of the parasite in the cerebrospinal 
fluid, and found there in practically every case (Bruce). 

This fluid should be centrifugalized gently for fully five minutes. 
It can then be poured off to the last drop into another tube and the 
sediment examined under a well ' vaselined cover-glass. If centrifu- 
galized too violently the motility of the parasites will be less, and they 
may be mutilated by the weight of the sediment. The fluid should be 
centrifugalized two or even three times, for none may be found in 
the first sediment. Not many are present. 

The parasite of man, Trypanosoma gambiense, can in no way 
be distinguished from that of the tsetse or surra, either morphologi- 
cally or pathogenically. 

There are two other forms of trypanosoma which are easily dis- 
tinguished from that of man, and which occur quite commonly. The 
one is Trypanosoma theileri, which is pathogenic for cattle alone, — 
it is a parasite from two to three times as long as the human form, — 
and the trypanosoma of rats, which is morphologically char- 
acteristic, since the posterior end is long drawn out and pointed, the 
centrosome is not near the end, but at the juncture of the posterior 
and the middle thirds. It can be easily distinguished from the other 
trypanosomata, even when they coexist in the blood. It occurs in 
about 10 to 30 per cent, of rats investigated in some regions, in 
others in even 90 per cent. 



640 



CLINICAL DIAGNOSIS 



For a recent discussion of the whole subject the reader is referred 
to the report by Musgrave and Clegg. 103 A recent good brief review 
is by Koch. 104 

Piroplasmosis. Infection with the Leishman-Donovan Bodies. — 

The Leishman-Donovan bodies (see Fig. 120) are small, oval, round, 
or oat-shaped bodies, from 2.5 to 3.5 microns in diameter. They have 
a definite cell outline and contain two chromatin masses, a larger one, 
the " nucleus," almost round or oval which stains faintly, and a smaller, 
bacillus-shaped " centrosome," which stains deeply, and which is di- 
rected either at right angles or nearly so to the axis of the nucleus. 
These two bodies are both in the long axis of the cell, the larger on 
the periphery. Many are vacuolated. The outline of the cell cannot 
always be seen, but these two masses thus arranged are distinctive. 
They are easily stained by the various polychrome methylene blue- 
eosin mixtures. They are best studied with the highest powers, the 
oil lens and V ocular. 

They are not found in the circulating blood, except a few intra- 
cellulars in two fatal cases, but easily in that from splenic puncture, 
and in the granulation tissue snipped off from the ulcers with scissors 
and crushed thin on the slide. At autopsy many are found in the 
mesenteric lymph-glands, bone-marrow, and liver. 

Some lie free but most seem to be intracellular, one or two in a 
leucocyte ( ?), from one to twelve in endothelial or splenic cells, some, 
even hundreds in large masses, in macrophages ( ?). These masses are 
variously interpreted. If cells, they are badly degenerated. Ross 
considers them to be a ''matrix" in which the organisms lie, and that 
none are intracellular, and Manson regards such masses as zooglia. 

Their division may be followed. It begins in the larger chromatin 
mass and ends in the smaller which may begin to divide after the 
fragments of the larger are widely separated. 

This parasite is supposed to be the cause of some cases of the chronic " ma- 
larial " cachexia of the Tropics, dum-dum fever, kala azar, tropical splenomegaly ; 
of the tropical ulcer, Delhi boil, Aleppo button, Scinde sore, oriental sore, etc. It 
is a filth disease. In the Tropics it promises to prove even more important than 
the malarial organism. Clinically there are great enlargement of the spleen, emacia- 
tion, irregular fever, various abdominal symptoms, and cutaneous hemorrhages 
and ulcerations. 

Donovan reports 72 cases, 105 with a mortality of 30.55 per cent. 

The blood features are a moderate anaemia, from 2,000,000 to 
4,000,000, and leucopenia, with a relative 1 and absolute increase of 
the large mononuclears. The average leucocyte count is about 

103 Biological Lab. Department of the Interior, Bureau of Government Labora- 
tories, 1903. 

10 *Deutsches med. Wochenschr., 1904, No. 47. 
105 Lancet, September 10, 1904. 




Fig. 120.— Leishman-Donovan bodies. From splenic puncture. X 1200. 



THE BLOOD: FILARIASIS 



641 



2000. In a case of Neave the large mononuclears were 67 per cent, 
(total count 3000) ; pmn. n., 20 per cent.; sm. monos., 11 per cent.; 
eosin., 1 per cent. ; myelocytes, 1 per cent. The patient was an eight- 
year-old boy. In most cases the formula is more nearly normal. 

These parasites were first described in 1900 by Leishman as degenerated try- 
panosomes, an idea which is now held by some. Whether related or not, it is 
agreed that these may show flagellated forms, and that degenerated trypanosomes 
can assume a form similar to this, but those interested refuse to find any relation- 
ship. 

Filariasis. — Of the various forms described in human blood, that 
most common is Filaria bancrofti (F. nocturna). These embryos 
are from 270 to 340 microns long, and from 7 to 1 1 broad (see Fig. 
121). They are enclosed in a sheath which is considerably longer 
than the parasite. The anterior end of the worm is abruptly rounded, 
with six-tipped prepuce and sharp fang; the posterior tapers off 
for two-fifths of its length. It has a granular median axis. At 



Fig. 121. — Filaria bancrofti. X 50. 

first their movement is progressive, but they seem soon to become 
attached to the glass at their anterior end, and there they remain, 
lashing the surrounding corpuscles for days. These embryos appear 
in the circulation towards evening, their number gradually rising to 
a maximum at about midnight, then diminishing toward dawn. Dur- 
ing the day they are in the internal organs, especially the lungs. 

Lothrop and Pratt 106 charted hourly the numbers counted, and 
found at midnight 2100 per cubic centimetre. 

The adults lie in the lymphatics, where they obstruct the lymph flow, causing 
lymph-scrotum, elephantiasis, occlusion of the thoracic duct, and various other 
lymph tumors. This obstruction is also attributed to the eggs, which are too wide 
to pass through capillaries. This is the chief cause of haematochyluria. The 
female is 85 to 150 mm. long, with a distinct neck, a head with simple minute 
terminal mouth, a plain cylindrical body covered by a striated cuticle, and which 
tapers to the neck and tail. The tail ends bluntly and has a small depression sur- 
rounded by two lips. The anus is a ventral opening on the summit of a trilobed 
papilla. 

106 Am. Jour. Med. Sci., November, 1900. 

41 



642 



CLINICAL DIAGNOSIS 



The ova are 25 to 38 microns long by 15 microns broad. The females are 
generally vivaparous, but may discharge the eggs. The embryos reach the general 
circulation through the thoracic duct. 

The male is 80 mm. long without neck, and a tendril-like tail rolled up in 
one or two spirals. The oesophagus is thick walled. The cloaca is ventral, with 
four pre-anal and four post-anal papillae and two spicules. 

The intermediate hosts are some varieties of Culex and Anopheles mosquitoes. 
About an hour after the bite the embryos in the mosquito's stomach cast their 
sheath. Some die, but others actively bore their way through the intestinal wall 
to the muscles, where they rest. During the next two or three days the embryo 
becomes larger and the alimentary tract develops. On the seventh day the worm 
is 1.5 mm. long and perfectly developed. It now actively travels to the head and 
takes its position in the labium, whence it enters its new host during the biting 
by piercing the delicate membrane of the end of the proboscis. It takes an infec- 
tion by even hundreds of these adult forms to cause a very severe case, and it 
may be years before any symptoms begin. 

The clinical symptoms, in addition to the various lymph tumors, are anaemia, 
enlarged spleen, and fever. In any case of lymph tumor, elephantiasis, hsemato- 
chyluria, the blood should be examined. These cases are usually admitted to the 
surgical side, and an interesting number have been operated on for inguinal hernia, 
the lymph-scrotum being thus interpreted. Probably there are a good many cases 
in this- country, judging from the number recently found in quite widely distant 
cities. 

It occurs endemic in the Tropics. In the Fiji Islands as much as 25 per cent., 
and in the Friendly Islands even 32 per cent., of the inhabitants are said to be 
infected with this disease, also called " craw-craw," or the " sleeping disease." 

The blood should be examined late at night. A very thick fresh 
specimen is made and examined with the low power. These worms 
cannot be overlooked. Their motion will continue for even a week in 
a well-sealed specimen. 

The hcematochyluria is due to rupture of the varicosed lymph- 
vessels of the bladder, these forming much of the collateral circula- 
tion which compensates for an occluded thoracic duct. The attacks 
may occur for even eighteen years, each being weeks or months long 
and separated by intervals of months or years. They come on 
spontaneously or following exertion, excitement, etc. The onset is 
with pain and fever. The sequence is, hematuria, haematochyluria, 
chyluria. In the urine are found embryos. The urine contains most 
blood and embryos in the early morning, most chyle after a rich 
meal (even 3.8 per cent. fat). (For the blood formula, see page 

535-) 

Filaria diurna (the embryos) differs little from Filaria nocturna (bancrofti), 
except that it remains in the circulation only during the day, and the adult form 
is not yet known (Filaria loa of the subcutaneous areolar tissue?). The granular 
axis fails. 

Filaria perstans. — These embryos are about 200 microns long and 4 to 5 in 
width, without a sheath, and with very active, progressive, as well as lashing 
motion. They remain in the circulation day and night. The body tapers for its 
posterior two thirds ; it has a slightly bulbous tail. 

The adult is situated in the retroperitoneal tissue. 

Other forms described in man are Filaria ozzardi (embryos small, 170 to 200 
microns long, without sheath and with sharp tail, no periodicity, its adult in the sub- 



spirochete of relapsing fever. 



THE BLOOD : KELAPSWG FEVER 



643 



peritoneal tissue) ; Filaria demarquai (embryos 200 microns long, sheathless, and 
sharp-tailed, with cephalic armature, no periodicity, adult doubtful) ; Filaria 
megalhaesi, Filaria gigas, and Filaria loa. 

Relapsing Fever. Famine Fever. — The spirochete of Obermeyer 
(see Fig. 122) is an organism usually curled like a corkscrew, from 
25 to 40 microns long and about 1 in width. No further structure 
is evident. It takes a deep chromatin stain. It occurs in the blood 
only during the febrile paroxysms of this disease. Nothing more is 
known as to its life history, but it is certainly a filth disease. It is 
actively motile, with a rapid, delicate, wavy motion, stretching and 
collapsing like a coiled spring, and also moving slowly along among 
the corpuscles, but seeming not to disturb them much. 

They appear one or two days before the paroxysm, at first a few,, 
then great numbers. Some are single, some twisted into snarls, and 
many are within leucocytes. With the fall in temperature they dis- 
appear until the next paroxysm. The fever continues for about six 
days ; the intervals are of about the same length. 

The " spores " seen in the plasma during the intervals are of doubt- 
ful significance (ha?mokonien granules?). The organisms can be seen 
to multiply in the specimen, also to die and to break up. 

OPSONINS.* 

Much interest has recently been excited by the report from certain 
observers of a newly discovered property of the blood. There is sup - 
posed to be present in the serum a " body," called an " opsonin," which 
influences phagocytosis by its action on the bacteria ; that is, which 
makes the organism attractive to the leucocyte. 

The experiment which is usually cited to demonstrate both the 
existence of opsonin and that its action is on the bacteria and not on 
the leucocytes, is the following: An emulsion of bacteria is made and 
divided into two portions, to one of which serum is added. Both 
tubes are placed in the incubator at Z7 X A° C. for about fifteen minutes, 
and then the bacteria in the tube to which serum was added are repeat- 
edly washed until all of the serum has been removed. Leucocytes 
washed free from serum are now added to both tubes. Under favor- 
able conditions the bacteria in the tube to which serum was added and 
then washed away will be ingested by the leucocytes, while those in 
the other will not. (More recent work throws considerable doubt on 
the exactness of the technic used in, and the correctness of the inference 
drawn from, this experiment.) 

But this test is not uniformly successful with all varieties of bac- 
teria, or absolutely successful with any one variety. Bacillus pyocya- 

* For the foliowing two sections I am indebted to Dr. Win. L. Moss. 



644 



CLINICAL DIAGNOSIS 



neus, for example, is readily phagocytized without the action of any 
serum, while a certain amount of phagocytosis of any variety of bac- 
terium takes place without the addition of serum — the so-called spon- 
taneous phagocytosis.* Also different strains of the same bacterium 
may show marked variation in their resistence to phagocytosis when 
under the influence of the same serum. In general, the more virulent 
the strain, the more resistent it is to phagocytosis. 

It is assumed that the bacteria which have been in contact with 
the serum have been acted upon by something in the serum which has 
changed them in some way essential to phagocytosis. This action is 
regarded as being probably a chemical one in which the bacteria 
take up the substance called " opsonin " and unite with it in such 
a way that it is not removed by repeated washing. That no such 
action is exerted by the serum on the leucocytes is evidenced by the 
fact that leucocytes, which have been in contact with the serum, are 
readily deprived of their ability to ingest any but opsonized bacteria 
by washing. 

Wright is the chief exponent of the opsonic theory. He and his 
numerous followers attach much significance to the estimation of the 
amount of opsonin in the blood, in the diagnosis of the bacterial dis- 
eases, and as a guide in their treatment by specific vaccines. They 
assume that the body furnishes a specific " opsonin " for each infecting 
organism. In case of an infection by some bacterium, therefore, we 
have only to try the patient's serum on a number of organisms and 
see which of them is attacked by leucocytes more or less vigorously 
than normal. If we find this is true for some one organism we may 
assume that this is the organism infecting the patient. 

Various methods have been devised for estimating the relative 
amount of opsonin in the blood, there being no means of arriving 
at the absolute amount present. The relative amount of opsonin con- 
tained in the blood is spoken of as the " opsonic index," and one 
attempts to arrive at this by observing the degree to which the serum 
of one individual influences phagocytosis as compared with the serum 
of another individual. 

The method most widely used in determining the opsonic index 
consists in bringing together equal volumes of leucocytes, bacteria, 
and serum, allowing phagocytosis to proceed a given length of time, 
counting in a stained smear the number of bacteria which a given 
number of leucocytes contain, and then determining the average num- 
ber of bacteria per leucocyte. A control is made at the same time in 
exactly the same way, but using the serum of a normal individual. 

*If the corpuscles and bacteria are suspended in 1.2 per cent, salt solution 
spontaneous phagocytosis is said not to occur. 



THE BLOOD ; OPSONINS 



645 



The average number of bacteria per leucocyte in this control specimen 
is the denominator of the fraction the numerator of which is the 
average of the specimen with the patient's serum. This fraction, or 
ratio, is the opsonic index. 

For example : Suppose the average number of bacteria taken up by 
the leucocytes in a preparation in which patient's serum has been used 
is 3, and the average number taken up by the leucocytes in a prepara- 
tion in which normal serum has been used is 6 ; the ratio is 3 : 6. The 
opsonic index expressed by this ratio is, therefore, 0.5. Had the aver- 
age number in the preparation in which patient's serum was used been 
9, the ratio would be 9: 6, and consequently the opsonic index 1.5. 

The technique described below is essentially that used by Wright, but as the 
sources of error are so great and so numerous, even with the best technique, certain 
refinements have been added. For the sake of definiteness the technique will be 
described in great detail, although it will readily be understood that certain modifi- 
cations might be made. The technique may, perhaps, best be described by taking 
a specific case, and as the Staphylococcus aureus is one of the easiest organisms 
with which to work, we will consider that one. The following preparations are 
necessary : 

1. An emulsion of leucocytes (obtained from any source) free from serum. 

2. An emulsion of Staphylococcus aureus. 

3. A specimen of normal serum. 

4. A specimen of the patient's serum. 

1. Preparation of leucocytic emulsion : A clean, sterile centrifuge tube is 
filled three-fourths full of a sterile solution containing 1.5 per cent, sodium citrate 
and .85 per cent, sodium chloride. The dorsal surface of the distal phalanx of the 
index or middle finger of the left hand is now cleansed with alcohol and wiped dry, 
the hand is swung briskly to and fro several times to congest it, and before the 
excess of blood has time to escape from the hand, a bandage, or piece of small 
rubber tubing, is wound tightly around the prepared finger, beginning at the base 
and extending down to or past the middle joint. (See Fig. 122a.) With a sharp 
blood sticker a prick is made in the cleansed area and ten drops of blood are allowed 
to flow into the centrifuge tube containing the sodium citrate solution. This is 
immediately mixed by drawing it up several times into a sterile 10 cc. pipette. 
The tube is now centrifugalized for about three minutes at a speed of 1500 to 2000 
revolutions per minute. The red corpuscles, being heavier, will occupy the bottom 
of the tube and will be covered with a very thin layer of leucocytes. The super- 
natant fluid will be clear or very slightly turbid from the still suspended platelets, 
or sometimes, perhaps, from the fat, etc.. contained in the serum. 

By longer centrifugalization the platelets can also be thrown down, but this is 
not desirable. Better and cleaner preparations are obtained if the platelets are 
not included. With a little experience one learns to judge by the degree of 
turbidity of the supernatant fluid when to stop the centrifugalization so as to get 
a maximum number of leucocytes with a minimum number of platelets. 

The supernatant fluid is now removed by means of a sterile pipette. For this 
purpose a 10 cc. pipette of the Mohr pattern fitted with a rubber bulb of 10 or 15 cc. 
capacity is very convenient. 

The centrifuge tube is now filled to within one or two centimetres of the top 
with sterile .85 per cent, salt solution and the corpuscles thoroughly mixed again 
by means of the pipette. The tube is replaced in the centrifuge, the corpuscles 
again thrown down, and the supernatant fluid removed. This washing with salt 
solution is repeated still again. 

After the third centrifugalization (once in sodium citrate solution and twice in 



646 



CLINICAL DIAGNOSIS 



sodium chloride solution) the supernatant fluid is pipetted off down to within one 
cubic centimetre of the surface of the corpuscles. 

The point of a capillary pipette is now introduced down to the surface of the 
corpuscles through the one centimetre of supernatant fluid and by means of a 
rubber teat the layer of leucocytes, together with a few red cells, may be drawn 
off and transferred to another tube. A small test tube, measuring 34 x 7 cm., is 
convenient for this purpose. 

The leucocytes which have been transferred in this way, together with the few 
red cells and small amount of sodium chloride solution necessarily brought over 
with them, are thoroughly mixed just before using by drawing into and expelling 
from the capillary pipette used in their transference. Care must be exercised to 
produce no air bubbles in this process, however. 

2. The preparation of the emulsion of bacteria : A twenty-four-hour slant agar 
culture of Staphylococcus is used for this purpose. 

Into a watch glass or small test tube are poured about three cubic centimetres 
of .85 per cent, sodium chloride solution. Some of the growth is removed from 
the culture tube with the platinum loop and is thoroughly rubbed up on the side 
of the watch glass (or small test tube) just above the level of the salt solution, 
the glass having previously been wet with the fluid by tilting. In this way the 
bacteria are gradually washed down into the salt solution. This process is repeated 
until the emulsion is slightly turbid. It should contain no clumps. 

To judge the degree of turbidity is a matter of experience. It is desirable to 
have an emulsion which will yield an average of about six bacteria per polymorpho- 
leucocyte. It will probably be necessary to test this by trial preparations. If the 
leucocytes are found to contain too many bacteria, the emulsion should be diluted ; 
if too few, more bacteria should be added to the emulsion. 

The securing of a good and uniform emulsion is further facilitated in the fol- 
lowing way : A capillary pipette fitted with a rubber teat and with the capillary 
end cut off perfectly even, is pressed squarely against the bottom of the watch 
glass and the emulsion drawn in and forced out of the tube a number of times., 
In passing through the narrow chink left between the bottom of the pipette and 
the watch glass, the small clumps are usually broken up. 

To produce a satisfactory emulsion one should use a rather moist growth of 
bacteria. Such a growth may be facilitated by using culture tubes containing 
a fair amount of water of condensation and media which are not too solid. Should, 
however, difficulty be experienced in getting rid of clumps, one may resort to the 
following additional procedure : An emulsion is made as above except, perhaps, 
slightly thicker. This is now centrifugalized for two or three minutes at 1500 to 
2000 revolutions per minute and the supernatant fluid, now free from clumps, 
pipetted off and used. 

3. The method of obtaining the serum : The serum is most conveniently obtained 
in glass tubes of the form shown in Fig. 122b. With a little practice these are 
easily made from ordinary glass tubing of about five millimetres internal diameter. 
They should be about ten centimetres in length. 

The blood is gotten from the finger as described for obtaining the leucocytes. 
(Fig. 122a.) The. curved end of the tube is touched to the drop of blood, the body 
of the tube being held at a lower level, but slanting somewhat, so that the blood 
will not run into the straight end. Having filled the tube half or two-thirds full, 
the end is warmed gently to expel some of the air, and then the point is sealed 
in the flame. As the tube cools the blood will be drawn from the curved end 
toward the straight end of the tube. Great care must be taken that in warming 
the tube the blood is not heated and that it does not run up into the straight end 
of the tube while it is still hot. When the clot has begun to form, the tube is 
placed in the centrifuge with straight end down and a few minutes' rotation serves 
to separate the serum. 

When ready to use the tube is marked across with a file about one centimetre 
above the level of the serum and broken off. 

Having now prepared an emulsion of leucocytes, an emulsion of bacteria, the 




Fig. 122b. — Tubes used in serum work. The tube to the left is used to collect hlood. The others for 
bacterium emulsions. (, Reduced just one-half). 



THE BLOOD: OPSONINS 



047 



specimens of the normal and of the patient's serum, the mixtures are made for 
phagocytosis. 

For this purpose one requires capillary pipettes, which are best made from 
glass tubing about five millimetres in diameter. The tubing is cut into about ten 
centimetre lengths, heated in the middle and drawn out into capillaries of about 
one millimetre diameter. These are now broken in two and the capillary ends cut 
of squarely at such a point as will leave the tube about twenty centimetres long 
over all. With a glass-marking pencil a fine mark is made on the capillary stem 
about two and a half centimetres from the small end. By means of this pipette 
the leucocytes, bacteria, and serum are measured and mixed as follows : The end 
of the pipette is placed in the leucocytic emulsion and by means of a rubber teat, 
the capillary is filled up to the pencil mark. A small bubble of air is now 
admitted, and the capillary again filled up to the mark with bacterial emulsion, the 
leucocytes, meantime, having been drawn farther up the capillary stem. Another 
bubble of air is now admitted and the capillary filled up to the mark with normal 
serum. We now have in the pipette equal volumes of leucocytic emulsion, bacterial 
emulsion, and serum, separated by two bubbles of air. The whole is now expelled 
on a perfectly clean slide and thoroughly and rapidly mixed by repeatedly drawing 
up into the capillary tube, care being exercised to avoid air bubbles. After thor- 
oughly mixing, the whole volume is drawn up into the capillary so that the lower 
end of the fluid is about three or four centimetres from, the capillary end of the 
tube, which is now sealed off in the flame, the tube numbered or lettered tO' designate 
the serum used, and placed in the incubator at 37^° C. 

A similar preparation is made in which patient's serum is used instead of the 
normal. Both preparations are kept in the incubator exactly the same length of 
time, fifteen minutes being the period adapted for most organisms. 

Preparation of the blood smears : After removing the pipette from the incu- 
bator it is convenient to use a rubber teat with a hole in the convex end for expell- 
ing and again mixing the fluid. The hole is readily made with a hot platinum 
needle. Such a teat is fitted over the open end of the pipette and the capillary 
end is then cut oft. The fluid can now be pressed out on a clean slide by placing 
a finger over the hole in the teat. After mixing the fluid well by drawing it into 
the pipette several times, a small drop, about one and one-half to two millimetres 
in diameter, is placed about two centimetres from the end of a perfectly clean 
slide. The spread is made with the end of another slide. The corner of the 
spreading slide is broken off so that the smear will not extend quite to the edges 
of the first slide. The angle at which the spreading slide is held to the other 
slide, the pressure and the rapidity with which the spread is made, are all factors 
in the result. Practice alone will enable one to become expert in this. 

A very satisfactory stain for most bacteria is Hasting's stain. With this stain 
the nuclei of the cells are blue, and the protoplasm a light pink. As the bacteria 
take the stain with more avidity than the nuclei of the cells, they can readily be 
•counted even when overlying the nuclei, provided care has been exercised not to 
stain the preparations too deeply. 

It is always desirable to make a duplicate preparation from each pipette. This 
duplicate is numbered and laid aside, usually without staining, and is available 
should the first slide not prove satisfactory. 

If the preparation has been successful, the leucocytes should be found 
abundantly toward the latter end of the smear. With the low power of the 
microscope one finds an area suitable for counting. The leucocytes should be 
well flattened out, the margins easily definable, and the cells not massed together in 
confusion. In a good preparation one should be able to count several hundred 
leucocytes, if desired, without spending too much time searching for them. In 
enumerating the bacteria one is sometimes at a loss to know whether to include 
bacteria which apparently lie just on the periphery of the cell. It probably does 
not make much difference whether they are included or not so long as one con- 
stantly follows the same rule, but it seems better, perhaps, to include only those 
bacteria which lie wholly within the periphery of the cell. 



648 



CLINICAL DIAGNOSIS 



The Count. — Most workers arbitrarily count only the bacteria included within 
the polymorphonuclear leucocytes. The number of leucocytes counted varies 
greatly in different laboratories. The larger the number counted, the more nearly 
will the result represent the true average. Not less than one hundred cells should 
be counted in each preparation. 

The Opsonic Index. — Having obtained the average number of 
bacteria per one hundred cells for the preparation in which patient's 
serum was used, and that for the preparation in which normal serum 
was used, the opsonic index is obtained by dividing the patient's 
average by the normal's average. 

The Value of the Opsonic Index. — Wright claims that in normal 
individuals the opsonic index is, within limits, constant. He allows 
a variation between .8 and 1.2 to cover the normal variation in the 
opsonic index plus errors in technique. An index below .8 or above 
1.2 is taken to indicate infection, and it may happen that an individual 
with an infection will give an index within the above limits, for he may 
have been caught just as he was crossing the normal line in passing 
from a low to a high, or a high to a low index. Wright lays great 
stress on a variable index as indicating infection. 

Controlling the Normal. — Instead of taking the serum of a single 
individual to represent the normal, it is much better to use several 
normal sera and take the average of all the normals as the normal 
figure. 

The practice of " pooling " the normals ; i.e., mixing all the normal 
sera and then putting up a preparation from such a mixture, is to be 
condemned. Such a method of control has no value. A separate 
preparation should be made from each normal serum and the count 
on each of these should come out within certain narrow limits of each 
other. The highest count on any one normal serum should not exceed 
the lowest count on any other normal by more than 15 per cent., and 
10 per cent, would be a safer limit. 

The partisans of opsonins hold to their specificity ; i.e.. the index 
shows a disturbed relation only for that organism which is responsible 
for the infection. E.g., a patient having a pure Staphylococcus infec- 
tion will have a normal index toward all organisms except Staphy- 
lococcus. If a patient has an infection of unknown etiology, and 
his index is tested toward a number of organisms and is found normal 
to all except one, the diagnosis can be made of infection with that 
organism for which the abnormal index exists. 

Normal and Immune Opsonins. — It has been shown that there are 
two kinds of opsonins, one thermo-labile, the other thermo-stable. 
The former is destroyed by heating to 57 0 C. for one-half hour. Cer- 
tain investigators hold that the normal opsonins are thermo-labile and 
non-specific, while the immune opsonins are thermo-stable and specific. 



THE BLOOD: OPSONINS 



649 



If this view is correct it would be advisable to inactivate the sera before 
attempting to use the opsonic index as a diagnostic aid. 

The Technique for Other Bacteria. — The technique has been de- 
scribed for Staphylococcus because it is one of the simplest organisms 
with which to work. The technique is practically identical for the 
Gonococcus, Bacillus typhosus, Bacillus coli, etc. Except for the latter 
two, a somewhat shorter incubation period, ten minutes, may be neces- 
sary, as many of the bacteria ingested may be digested by the leucocytes 
in fifteen minutes. 

It is necessary to say a word about the estimation of the tuberculo- 
opsonic index, the preparation of the bacillary emulsion and the 
staining being different from that above described. 

The Emulsion. — On account of the danger of working with living tubercle 
bacilli, and the difficulty of obtaining a good emulsion, the dead bodies of the 
bacilli are generally used. These one can obtain easily from the manufacturers of 
tuberculin, or he can grow the tubercle bacilli and kill them by heating prior to 
making the emulsion. It is, perhaps, more convenient to use the dead and dried 
bodies obtained from the tuberculin manufacturers. 

About Y% to gramme is placed in a small agate mortar and ground in the dry 
condition until very finely divided. Normal salt solution is now added, drop by 
drop, the grinding being meanwhile continued. Having reached the proper degree 
of dilution, a fair degree of turbidity being desirable, the emulsion may be either 
centrifugalized immediately to remove clamps or sedimented gradually. For the 
gradual sedimentation the emulsion is placed in a sterile test tube which has been 
heated and drawn out in the form indicated in Fig. 122b (middle tube). 

If the neck is so narrow that the fluid does not readily run down into the tube, 
it may be filled by the following simple procedure : Some of the air is expelled 
from the tube by gently warming it ; a part of the emulsion is poured in the upper 
expanded portion of the tube and as the air cools in the lower part, the fluid is 
drawn down into the tube. By repeating this process the tube can be filled one- 
half or two-thirds full. The upper end of the tube is now melted off and the tube 
sealed in this way. It is then inverted and allowed to stand, point downward, until 
all the clumps have settled into the neck of the tube. This may require a week 
or two, and if the bacilli have been well ground up in the mortar, the supernatant 
fluid, after sedimentation, will still remain slightly turbid, and on examination will 
be found to contain almost exclusively single bacteria, or groups of not more than 
two or three. 

The neck of the tube is now marked across with a file at a point just above 
the level to which the clumps reach, and by carefully breaking the neck off at this 
point, one may get rid of the clumps. 

There are several drawbacks to using an emulsion prepared according to the 
method just described, one of which is that many of the bacilli are fragmented. 

Some workers count each fragment as a whole bacillus, while others attempt 
to estimate by their length the fraction of a bacillus which is represented, both 
proceedings being equally objectionable. 

There are perhaps some advantages in using an emulsion of living tubercle 
bacilli, although one must constantly bear in mind the danger.* 

It is usually stated to be difficult to obtain a uniform emulsion of living 
tubercle bacilli. By selection, however, strains of tubercle bacilli can be found 

* Jeans and Sellards, Johns Hopkins Hospital Bulletin, 1907, have described 
an excellent method for preparing the emulsion in which the tubercle bacilli are 
sterilized by exposure to sunlight. 



650 



CLINICAL DIAGNOSIS 



which emulsify easily, or one may follow the methods described for producing 
homogeneous cultures of tubercle bacilli. Tubercle bacilli should not be sterilized 
by heat after being emulsified, as the heat causes them to clump again. 

Staining Tubercle Preparations. — The blood smears are made in the same 
way described above for Staphylococcus. They are fixed either by heat, methyl 
alcohol, or by immersing for one or two minutes in a saturated solution of bichloride 
of mercury. They may then be stained in hot carbolfuchsin for five minutes or 
placed in a staining dish, covered with carbolfuchsin and allowed to stand over 
night in the incubator. Decolorization is accomplished with 95 per cent, alcohol, 
and counterstaining with an aqueous solution of methylene blue. The red cells 
may be gotten rid of before staining by immersing the slide in dilute acetic acid, 
but if the blood smear has been properly made, this will not be necessary. 

Other Methods of Estimating the Opsonic Index. — The above technique is, 
perhaps, the one most extensively used in the estimation of the opsonic index, but 
various other methods have been proposed and used. 

It is not necessary to work with such minute quantities of material as described 
for the capillary method, although it is convenient. Neither is it necessary to 
combine the leucocytic emulsion, bacterial emulsion, and serum in equal quantities. 
Instead of using capillary pipettes one may measure the emulsions and serum in 
standard one-cubic centimetre pipettes graduated into one-tenths, and incubate 
the mixture in small test tubes. On account of the usual difficulty of obtaining 
large quantities, especially of leucocytes, it is not convenient to employ more than 
0.2 to 0.3 cubic centimetre of each in the mixtures. In preparations made in this 
way the leucocytes usually settle to the bottom of the tube during incubation and 
may be removed in a mass with the platinum loop when one makes the smears. 
The leucocytes thus removed are spread on the slide with the loop and may then 
be stained and counted as describe'd above. 

Method of Dilution. — A series of progressive dilutions of the serum may be 
made and preparations put up from each of the various dilutions, and that beyond 
which phagocytosis practically ceases, noted. By a comparison of the degree of 
dilution beyond which phagocytosis ceases for normal and for patient's serum, an 
opsonic index can be calculated. E.g., if phagocytosis ceases beyond a dilution of 
1-100 for normal serum and J -^o for patient's serum, the opsonic index of the 
patient would be 0.5. 

Considerable work has been done to test the practical value of the 
opsonic index. The experience at the Johns Hopkins Hospital may be 
found in the Johns Hopkins Hospital Bulletin, June-July, 1907, and 
attention is called to " An Inquiry into the Value of the Opsonic 
Index." by Fitzgerald, Strangways and Whiteman in the Bulletin of 
the Committee for the Study of Special Diseases, Vol. 1, No. 8, 
August, 1907. At present the status of the opsonic theory seems 
unsettled. The technique usually employed seems too inaccurate to 
be relied upon as a diagnostic aid, or as an indication for the treatment 
by means of vaccines. 

Whatever method is followed care should be taken to use a prac- 
tically aseptic technique, and that the leucocytic emulsion be prepared 
as short a time as possible before using. 

It is usually stated that the serum may be used any time within 
twenty-four hours, but it seems desirable to make the test within a 
few hours after the specimen is taken. 

It is of the utmost importance that anyone who takes up opsonic 
work should carefully test the accuracy of the technique for himself. 



THE BLOOD: OPSONINS 



651 



This should be done first, by making duplicate counts on the same 
slide; second, by comparing- counts made on several slides made from 
the same leucocytic and bacterial emulsions and the same serum ; 
third, by comparing counts made on preparations from the same leuco- 
cytic and bacterial emulsions but from several different normal sera. 

Until these counts come out within a reasonable limit of accuracy 
it is useless to go on to the estimation of the variation of the amount 
of opsonin in health and disease. 

FIXATION OF COMPLEMENT 

Before considering the technique required in this test some under- 
standing of its theory and nomenclature should be had. 

Certain infective agents, bacterial or other, when introduced into 
the body stimulate the cells of the body to produce defensive substances 
called ''antibodies." These antibodies may be of different sorts; 
antitoxins, bacteriolysins, agglutinins, precipitins, etc. Some of these 
antibodies fulfil their functions unaided, as diphtheria antitoxin, 
others require for their action some " complement," a substance found 
normally in the serum. 

Antibodies which require complement for their action are known 
as " amboceptors," " intermediary bodies," etc. Infective agents 
which are capable of stimulating the cells of the body to the production 
of antibodies are spoken of as " antigens." 

Antigens which stimulate the production of amboceptors are capa- 
ble of uniting with the corresponding amboceptor and the antigen- 
amboceptor combination is capable of uniting with complement. 

A diagnosis of infection with a given infective agent can be made 
if we can find the infective agent (antigen) or the corresponding anti- 
bodies in the blood or tissues of the body. For instance we make a 
diagnosis of typhoid fever if we can find in the blood of the patient 
either Bacillus typhosus, the antigen, or, by the Griiber-Widal test 
can demonstrate the typho-agglutinins. The demonstration of 
specific amboceptors is used in bacteriolytic and precipitin tests. 

The " fixation of complement " test may be described as follows : 
Here is a patient who has lues, a disease caused by Treponema pallida 
(the antigen). Since he has lues, the antibodies of this antigen will 
quite surely be present in his serum. We therefore obtain some of 
his serum and add to it this antigen (which we obtain from the body 
of a luetic foetus). This antigen, and its antibody, will unite, but 
into this combination will enter also some of the normal complement 
of this patient's blood. That amount of complement is, therefore, 
" fixed," that is, is now not free to fulfil any other function. To 
determine whether this serum now contains any free complement or 



652 



CLINICAL DIAGNOSIS 



not, we add to it red blood-corpuscles and a serum which will rapidly 
destroy these corpuscles by haemolysis, provided free complement is 
present. If these corpuscles are destroyed we know that our luetic 
antigen-antibody combination has not " fixed " all the complement. 
If they are not destroyed we know that there is no free complement 
present. 

The test, therefore, depends upon the presence of specific ambocep- 
tors (bacteriolytins, precipitins, etc.) in the serum of the suspected 
individual. This test becomes available only when one has some means 
of determining if complement has been fixed, or absorbed, by the 
infective agent (antigen) when patient's serum has been added. 

The indicator used to demonstrate the fixation of complement con- 
sists of inactivated hemolytic serum plus an emulsion of the corre- 
sponding red blood-cells. Such an indicator is spoken of as the 
" hemolytic system." Its action may be explained as follows : if red 
blood-cells free from serum are added to an inactivated haemolytic 
serum (containing no complement) no haemolysis will occur. If 
serum containing complement be added, haemolysis ensues. If now 
we take serum from a suspected patient and add to it antigen and 
complement, the complement will be bound to the antigen, provided 
the specific amboceptor is present in the patient's serum ; and if to 
such a mixture we now add a hemolytic system, no- haemolysis results, 
since there is no free complement available. Should, however, haemo- 
lysis occur it is evident that free complement was present. 

Thus the absence of haemolysis indicates the presence of the specific 
amboceptors in the patient's serum and a positive diagnosis, while the 
presence of haemolysis indicates the opposite condition. 

The technique will be described for the diagnosis of syphilis, and the application 
of it to other diseases can readily be made. 

For carrying out the test five preparations are necessary : 

1. Extract containing antigen. 

2. Serum to be tested. 

3. Complement. 

4. Hemolytic serum. 

5. A suspension of red blood-corpuscles. 

1. Preparation of Extract Containing Antigen. — The spleen and liver of a 
syphilic foetus are removed aseptically ; twenty grammes of the two are taken, 
using about equal portions of each, and minced very fine with sterile scissors. 
This is placed in a flask with 80 cc. of .85 per cent, sodium chloride solution con- 
taining .5 per cent, carbolic acid and agitated on a shaking machine for twenty-four 
hours. 

After removing from the shaking machine, the heavier particles are allowed 
to settle to the bottom, and the supernatant fluid is poured into centrifuge tubes 
and centrifugalized until practically clear supernatant fluid can be removed. 

This extract contains the antigen and may be kept in the refrigerator without 
undue deterioration for perhaps as much as six or eight weeks. 

Another method of preparing the antigen is to grind up the spleen and liver 
of a syphilitic foetus and dry them in a dessicator and then reduce them to a 



THE BLOOD: OPSONINS 



653 



powder by grinding in a mortar. When ready to use, an extract is made by adding 
a small quantity of this powder to normal salt solution. 

It is claimed that the antigen can be preserved a longer time in the dry state. 

2. Method of Obtaining the Scrum. — The patient's arm is cleaned up as for a 
blood culture, and by means of a syringe, 10 cc. of blood are obtained from one of 
the veins at the bend of the arm. This is placed in a sterile centrifuge tube and 
allowed to clot. The clot is separated from the walls of the tube by means of a 
sterile platinum needle and the separation of the serum is facilitated by centrifuga- 
lization. This is best done immediately after the clot has formed before it becomes 
too solid. The serum is removed from the tube by means of a sterile pipette, 
care being exercised not to get any blood-corpuscles with it. It is placed in a 
small test tube and inactivated by heating it in a water bath of 57 0 for thirty 
minutes. This inactivation consists in destroying the complement which the serum 
contains. 

3. Method of Obtaining the Complement. — Complement is used from an 
extraneous source in order that the amount of complement introduced in all of 
the controls may be the same as that used in the test. 

Any normal serum may be used as a source of complement. Guinea-pig serum 
is convenient, however, and contains a relatively large amount of complement. 

A guinea-pig is anaesthetized, the carotid artery isolated, and opened and the 
blood collected in a sterile centrifuge tube. The serum is separated as described 
above for patient's serum. In this case, however, it is not heated, as that would 
destroy the complement. 

The complement may be preserved as long as a month by keeping the serum 
in an ice chamber at o° to — 5 0 C. At this temperature the serum remains frozen. 
If an ice chamber is not at hand, fresh normal serum must be obtained each time 
the test is made, as the complement is an extremely labile body, and disappears 
when the serum stands for a day or more exposed to light and at ordinary 
temperature. 

4. The Hccmolytic Serum. — This may be obtained by immunizing any animal 
to the red blood-corpuscles of another species. The serum of many animals is 
normally hemolytic for the red blood-cells of other species, but this power may 
be greatly increased by a process of immunization, thus rendering the indicator 
to be used much more sensitive. 

It is convenient to immunize rabbits to sheep, guinea-pig, beef, or fowl cor- 
puscles. The rabbits may be inoculated intravenously with washed corpuscles, 
beginning with a dose of one-half or one cubic centimetre, and repeating the 
inoculations at intervals of four or five days, increasing the dose gradually up to 
two or three cubic centimetres of corpuscles, giving in all four or five inoculations. 

The hemolytic strength of the serum should now be tested as follows : Five 
or six days after the last injection, two or three cubic centimetres of blood are 
drawn from the ear vein of the rabbit, the serum separated and inactivated. 
Progressive dilutions of the serum are made, beginning with a dilution of perhaps 
one to ten and progressing by doubling up to one to eighty, then beginning with one 
to one hundred and progressing by hundreds up to one to two thousand. One 
cubic centimetre of each dilution is placed in a test tube and one cubic centimetre 
of a one to ten dilution of normal serum (complement) and one cubic centimetre 
of a 5 per cent, suspension of red corpuscles of the kind used in inoculating the 
rabbit are added to each tube. 

The tubes are allowed to stand in the incubator at 37V 2 ° C. for two hours, 
after which one notes the maximum dilution in which haemolysis has occurred. 
This dilution represents the " titer " or hemolytic strength of the serum. 

If the hemolytic strength is not found sufficiently high, one may resort to 
an intraperitoneal injection of 4 or 5 cc. of corpuscles. After five or six days' 
time another test is made. 

One should not be satisfied with a serum which will not hsemolyse completely 
in a dilution of one to four hundred, and a serum of greater strength is desirable. 

If the hemolytic strength of the serum is now found sufficiently high the 



654 



CLINICAL DIAGNOSIS 



animal is bled to death, the serum separated and distributed in a number of small 
test tubes ; 2 or 3 cc. of serum being placed in each. " 

The upper ends of these tubes, which have previously been drawn out so as 
to form narrow necks, are now sealed off in the flame. 

The serum is inactivated by placing the sealed tubes in a water bath at 57 0 C. 
for ]/ 2 hour. • 

If the technique has been aseptic the haemolytic serum may be preserved in a 
cool dark place for months. 

The following is one of the methods used in the laboratories of the Gesund- 
heits-Amt in Germany for the conservation of immune sera. 

Carbolic acid, 5.5 cc. 

Glycerin, 20.0 cc. 

Dist. water, q.s. ad 100.0 cc. 
Sig. — To every 10 cc. of serum add 1 cc. of the above mixture. 
The serum so treated is said to preserve its activity for years. 
It seems better, however, to depend upon an aseptic technique rather than upon 
antiseptics for the preservation of serum. 

In performing the fixation of complement test, the hemolytic serum is used 
in one-half the maximum dilution in which haemolysis has occurred. Thus, if 
the hemolytic serum has a titer of 1 : 2000, it is used in a dilution of 1 : 1000 in 
the test. 

5. Suspension of Red Blood-Cells. — A 5 per cent, suspension of washed cor- 
puscles of the kind used in producing the haemolytic serum is made in .85 per 
cent, sodium chloride solution. 

A sixth preparation consisting of normal human serum is necessary as a 
control. This is collected and inactivated in the same way as described for the 
patient's serum. 

The Test. — Reference to the following protocol will facilitate a description of 
the proceeding, and at the same time illustrate a convenient method of recording 
the results. 



Tube 
No. 


Antigen. 


Pts. Serum. 


Comple- 
ment. 




Haemolytic 
Serum. 


Corpuscles 




Haemolysis. 


I 


I.O CC. 


I.O CC I- 5 


1.0 cc. 


u 


I.O CC. 


I.O cc. 


0 


Absent 


2 


1.0 cc. 


I.O CC. I-IO 


I.O CC. 


0 
10 


I.O CC. 


1.0 cc. 


0 
10 


Absent 


3 


1.0 cc. 


1.0 cc. 1-20 


I.O CC. 




I.O CC. 


1.0 cc. 


-M 

CT3 

rA 


Absent 


4 


1.0 cc. 


1.0 cc. 1-40 


I.O CC. 




I.O CC. 


1.0 cc. 


Partial 


5 


1.0 cc. 


1.0 cc. 1-80 


I.O CC. 


rt 


I.O cc. 


1.0 cc. 


Complete 


6 


NaCl. 


NaCl. 


I.O CC. 


u 

XI 


1.0 cc. 


1.0 cc. 


>- 

si 


Complete 


7 


NaCl. 


1.0 cc. 1-5 


I.O CC. 




1.0 cc. 


I.O cc. 




Complete 


8 


1.0 cc. 


NaCl. 


I.O CC. 


bate 


1.0 cc. 


T.O CC. 


bate 


Complete 


9 


1.0 cc. 


1.0 cc. 1-5 


Nacl. 


1.0 cc. 


I.O CC. 


Absent 


10 


Nacl. 


1.0 cc. 1-5 


1.0 cc. 


u 


NaCl. 


I.O cc. 


u 


Absent 


11 


1.0 cc. 


Nor. serum 1-5 


I.O cc. 


C 


1.0 cc. 


1.0 cc. 


c 


Complete 



Sterile test tubes are numbered and placed in a rack. Two cc. of the extract 
containing the antigen are diluted with 8 cc. of .85 per cent, sodium chloride 
solution, making a 1 : 5 dilution. Progressive dilutions of the patient's serum are 
made, beginning with 1 : 5 and increasing by doubling the dilution, up to 1 : 80 
or 1 : 160. 

One cc. of the normal serum containing complement is diluted with 9 cc. of 
.85 per cent, sodium chloride solution, making a 1 :io dilution of complement. 

Ten cc. of a dilution of the haemolytic serum are made, the dilution being one- 
half of the maximum dilution which will give complete haemolysis ; and finally a 
50 per cent, suspension of washed corpuscles is made, the diluent being .85 per 
cent, sodium chloride solution in all cases. 



THE BLOOD: OPSONINS 



655 



The tubes are filled as indicated in the protocol under columns marked Antigen. 
Patient's serum, and Complement. They are now allowed to remain in the incubator 
for one hour at 37^2° C. After this the hemolytic serum and corpuscles are added 
and the tubes left in the incubator for two hours, at the end of which time the 
readings are made. 

It is customary to place the tubes in a refrigerator over night and make the 
final readings after twelve to eighteen hours. 

All of the work should be done with care to asepsis, since the introduction of 
contaminating bacteria in any quantity may vitiate the results, especially as certain 
bacteria will produce haemolysis by their growth in a medium containing red 
blood-cells. 

If the patient's serum contains the specific amboceptors no haemolysis should 
be present in the tubes containing patient's serum, at least none in the lower 
dilutions ; the complement having been fixed to the antigen by the amboceptors 
present is therefore not available to bring about haemolysis when the haemolytic 
system is added. 

The other tubes are controls and are of great importance. 

The sixth tube is a control of the haemolytic system and should show that it 
is effective. 

The seventh tube is to show that the patient's serum alone is not capable of 
fixing complement. 

The eighth tube is to show that the antigen alone is not capable of fixing 
complement. 

The ninth tube is to show that neither the antigen nor the patient's serum 
contains free complement. 

The tenth tube is to show that the patient's serum itself, in the minimum 
dilution used, is not haemolytic for the red corpuscles used. 

The eleventh tube is to show that normal serum does not contain the specific 
amboceptors. 

One further control is desirable, although it is not necessary if all of the other 
results have been consistent. This control consists of using an extract of normal 
foetal spleen and liver, with patient's serum, complement, and haemolytic system. 
In this test the haemolysis should be complete, showing that the amboceptors con- 
tained in the patient's serum are specific for the antigen used in the preceding 
tubes. 

It must be remembered that this test is to a certain extent 
a quantitative one. If the amount of antigen or patient's serum used 
is too small to fix all of the complement present, the excess of comple- 
ment remaining free may go to complete the action of the haemolytic 
system with resulting haemolysis. 

On the other hand, if an excessive amount of extract or serum be 
used, the complement may be bound even though no specific antigen or 
amboceptors be present. 

Inasmuch as it is impossible to say that equal quantities of the 
organs of two syphilitic foetuses will contain the same amount of 
antigen, each extract may be of a different strength, so> that it may be 
necessary to determine by experiment the proper quantity of extract 
to use for each new lot made. 

The test as applied to the bacterial diseases is practically the same 
as that given above except that, with most of them, the antigen may 
be obtained directly from pure cultures of the infecting micro- 
organism. 



656 



CLINICAL DIAGNOSIS 



It is usual to use in such cases extracts of the bacilli, although 
in the case of tuberculosis certain workers use tuberculin as a source 
of the antigen. 

The fixation of complement method seems a reliable and useful 
method of diagnosis for syphilis and certain of the parasyphilides as 
tabes, and general paresis, and is of great interest in confirming the 
luetic origin of these latter two diseases. 

The method further seems reliable as a diagnostic aid in typhoid, 
paratyphoid, colon infections, cholera, dysentery, gonorrhoea, and epi- 
demic meningitis, and will doubtless be extended to other bacterial 
diseases. As yet its value in the diagnosis of tuberculosis does not 
seem established. 

In the preceding pages it has been shown how, starting with a 
known antigen, one may determine the presence or absence of specific 
amboceptors in the serum of a given individual. 

It will readily be seen that, starting with a serum known to contain 
certain amboceptors, one can apply the same principles, in determining 
if a given extract contains the corresponding antigen. 

A further interesting application of the method is in determining 
the etiology of certain infectious diseases where the causattive factor 
is still in doubt. Extracts may be made of the supposed infective 
agent and the serum of patients suffering from the disease tested for 
the corresponding amboceptors. 

Finally it may be mentioned that other body fluids besides the 
serum may contain amboceptors, e.g., spinal fluid, pleural, and ascitic 
effusions, etc., although it is better and more convenient to use the 
serum in the test. 



CHAPTER VI 



EXAMINATION OF VARIOUS FLUIDS 

Among these are the plasma, serum, lymph, the cerebrospinal, the 
various transudates and exudates, the cystic fluids, the synovial and 
amniotic fluids. 

Specific Gravity. — This may be determined with an accurate aerometer (see 
page 95). Our figures given in the following pages were determined gravi- 
metrically. 

Dried Constituents. — In a weighed glass dish with a ground-glass stopper 
are weighed or measured from 10 to 30 cc. of the fluid in question. This is 
evaporated over a water-bath and then in vacuo over sulphuric acid. It is then 
dried at about no 0 to constant weight, no higher if urea or other fragile bodies, 
as is usually the case, are present. 

Proteids. — In all may occur serum albumin, serum globulin, in some fibrino- 
gen ; the albumoses are rare. True peptone is said never to occur, while the 
glyco-proteids and the phospho-proteids occur in some ; e.g., the cystic fluids. 

For examination of the proteids it is first necessary to remove the organized 
structures. This may be done by sedimentation, centrifugalization, filtration through 
paper or Kieselguhr. If fibrin is present, it will be evident to the naked eye, and 
shown positively by the rapid solution of the clot in artificial gastric juice, and its 
glassy swelling on the addition of 0.1 per cent, hydrochloric acid. 

Albumin, Globulin, Fibrinogen. — From 20 to 50 cc. are mixed with an equal 
amount of saturated (NFLOoSOi and allowed to stand one hour. The amount 
chosen should not contain more than 0.2 to 0.3 gm. of proteid for each precipitate. 
It is then filtered through a weighed filter, the precipitate washed with half-satu- 
rated (NFD2SO1 until the filtrate gives no cloud with acetic acid and K 4 FeCN 6 . 

(a) The filtrate is boiled, acetic acid added until faintly acid, it then boiled 
again, and filtered through a weighed ashless filter. The precipitate is washed with 
hot water, then with alcohol, then with ether, and brought to a constant weight at 
120 0 C. It is then ashed and the weight of this subtracted to give the weight of 
the albumin. 

(b) The precipitate on the filter paper is heated to no°, washed with hot 
water, then alcohol and ether, dried to constant weight, and its ash subtracted. This 
will equal the weight of the serum globulin and fibrinogen. 

For the determination of both together, see page 661. 

Glyco-proteids and Phosphorus-containing Proteids. (i) Mucin. — In gen- 
eral 100 cc. of fluid, diluted if necessary with water, are precipitated with acetic acid, 
filtered, and the precipitate washed with water acidulated with . acetic acid. The 
precipitate is then dissolved in weak alkaline water, and reprecipitated with acetic 
acid. 

A. Mucin. Mucoid. — A part of this precipitate is boiled on the water-bath 
with dilute mineral acid (HC1) and filtered, and the filtrate tested for sugar. 
The reduction of the copper is not as ready as by pure glucose solutions, hence 
considerable boiling may be necessary, and the reduced copper seen only after the 
fluid is cold and the precipitate settled. 

Mucin is a glyco-proteid of a stringy consistency, insoluble in acetic acid even 
in excess. Mucoid is similar in nature, but differs in some physical characteristics. 
A sharp line cannot be drawn (see page 221). 

B. Phosphorus-Containing Proteid. — A part of the precipitate is examined 
for organic phosphorus. It is ashed, the ash dissolved in dilute HNO.s, heated to 
boiling, concentrated somewhat, and then ammonium molybdate added in excess. 
A yellow color, and then a yellow precipitate which forms most readily at 40 0 C, 

42 657 



658 



CLINICAL. DIAGNOSIS 



is evidence of phosphoric acid. Or the precipitate may be dissolved in HQ, 
made strongly alkaline with ammonia, and then magnesium mixture added. The 
white precipitate of NH4MgP04 indicates phosphoric acid. 

If the reaction for phosphorus be merely faint the test has no meaning, since 
all of the phosphates and lecithin cannot be washed from the mucin precipitate. 

If organic phosphorus has been found, a part of the original precipitate is 
dissolved in NaOH, then HQ added, boiled to clear solution, supersaturated with 
ammonia and then precipitated with AgN0 3 . A flocculent cloud indicates a nucleo- 
proteid, the silver salt of the nuclein base being precipitated. If none forms, the 
phosphorus body is a paranucleo-proteid. 

Fat, Lecithin and Cholesterin. — To from 20 to 50 cc. of the fluid, weighed 
or measured, are added from 3 to 4 volumes of absolute alcohol. This is allowed 
to stand until the next day with repeated stirrings, then filtered, the precipitate 
washed with absolute alcohol, and the precipitate placed in the cylinder of a Soxh- 
let ether-extraction apparatus. The alcohol filtrate is neutralized and evaporated 
at 6o° C. The residue is taken up with alcohol and ether and re-evaporated. The 
residue is then taken up with ether and placed in the flask of this same Soxhlet 
apparatus. The precipitate is then extracted for hours. The ether extract is 
evaporated, the residue taken up in water-free ether, the filtered solution evaporated 
in a weighed beaker, and dried in vacuo over sulphuric acid to constant weight. 
This will be the combined weight of the fat, lecithin, and cholesterin. 

This residue is dissolved in alcohol, alcoholic KOH added, and it warmed on 
the water-bath for one hour, then evaporated to dryness. The fat is now soap 
and glycerin. To the residue is now added water (not too little) and this shaken 
out several times with equal volumes of ether. 

The ethereal extract is distilled to small volume, then evaporated in a weighed 
beaker to dryness. The residue contains soap and cholesterin. The former may 
be washed out with cold alcohol (small portions) slightly acidulated with HQ. 
The cholesterin left is dried at 8o° C. and weighed. 

The alcohol washings with the soap are added to the water extract of the 
previous separation, which now contains all the lecithin-phosphorus. This fluid 
is evaporated, the residue ashed, and the phosphorus determined. 

(Distearyllecithin contains 3.84 per cent, of phosphorus, dipalmityllecithin 4.12 
per cent.) 

Leucin. Tyrosin. — The fluid is examined as fresh as possible. All of the 
albumin is removed by heat and acetic acid, or by precipitation with from three 
to four volumes of alcohol, heating on the water-bath, cooling, and filtering. The 
alcohol is removed by evaporation. The filtrate is precipitated with neutral, then 
with basic, lead acetate, avoiding carefully any excess, and filtered. The lead is 
removed from the filtrate, with H2S, the filtrate evaporated, and examined for crys- 
tals (see page 259). 

Succinic Acid, CH 2 COOH.CH 2 COOH. — This acid occurs in 
many animal fluids in traces ; sometimes in the fluid of hydrocephalus 
and hydrocele, much in echinococcus cysts, and in wool-fat. It is 
formed by the bacterial decomposition of proteids and sugar. It 
frequently occurs in acid milk in the intestine, in putrid pus, and in 
the alcoholic fermentation of sugar. 

The fluid is freed of albumin by heat plus acetic acid. If it be urine which is 
tested, the albumin is first removed, the urine perfectly precipitated with baryta 
water, and the excess of this removed by H2SO4. The filtrate is evaporated to a 
residue, acidified with HQ, and extracted repeatedly with ether. The ether is 
evaporated off, the residue taken up with a small amount of water, and allowed 
to stand until crystallization. Or, the watery solution may be heated to boiling, 
nitric acid added drop by drop until it takes a slight yellow color, then evaporated. 
If no crystals form a portion of the residue is fused in a test-tube with ammonia 



BODY FLUIDS 



659 



and zinc dust. If a match-stick wet with strong sulphuric acid is held at the 
mouth of the tube, the red color of pyrrol indicates succinic acid. In this test, 
however, haemin and the indol derivatives must be excluded. These latter will 
give the reaction on heating alone. Haemin on heating with zinc dust alone. 

Lactic Acid, C 3 H 6 O s . — Of the three modifications of lactic acid 
the inactive, or lactic acid of fermentation, occurs oftenest in the 
stomach and intestine of man. The dextrorotatory form, or sarcolactic 
acid, occurs in the muscles, blood, pericardial fluid, aqueous humor, 
and intestinal contents. It occurs also in the urine in acute yellow 
atrophy and phosphorus poisoning, liver cirrhosis after respiratory 
distress, severe exercise, and before death. It occurs in pathological 
transudates often in abundance, in the bones in osteomalacia, and 
in the sweat in puerperal fever. The lasvorotatory form has never 
been found in the body. 

The fluid to be examined is made, if necessary, faintly acid with dilute H 2 S0 4 , 
boiled and filtered to remove the albumin. Baryta water is added as long as a 
precipitate forms, and the excess of the barium removed with C0 2 . The filtrate 
is evaporated to a thin syrup, without heating above 70 0 , in order to avoid the brown 
color. Absolute alcohol to about ten volumes or more in amount is then added 
slowly to the syrup, it is well stirred, allowed to stand for some time, then poured 
Off. The residue is dissolved in a little water. The procedure is repeated with 
alcohol once more, continuing in the same way. The alcoholic solution is poured 
off, filtered, the alcohol distilled off to a thin syrup, and the residue digested on 
the water-bath at a moderate temperature to drive off the alcohol. It is then 
cooled. To the thin syrup is added an equal amount of dilute phosphoric acid ; 
it is brought into a large flask and shaken out with a large amount of ether which 
gradually takes up the lactic acid. The ether must be frequently renewed. The 
united ether extracts are then filtered clear, the ether distilled off, the residue dis- 
solved in water, boiled for some time with an excess of ZnCOs, filtered, washed 
with hot water, evaporated to a small volume on the water-bath, and allowed to 
stand until the zinc salt of lactic acid crystallizes out. Alcohol is then added to 
the mother liquid, and it allowed to stand longer, and another mass of crystals is 
obtained. The zinc salt is dissolved in hot water and the zinc precipitated by 
H 2 S. The filtrate is then evaporated to a syrup containing the lactic acid. 

It is wholly untrustworthy to attempt to recognize lactic acid simply from its 
crystalline form or by Uffelmann's test alone. 

Inosite C 6 H 6 (OH) 6 . — This occurs in the urine of diabetics, in 
albuminuria, traces perhaps in each normal urine, but especially in 
polyuria, and in the echinococcus cysts. 

The albumin is removed by heat, the phosphates precipitated by baryta water, 
the filtrate evaporated, and the creatinin allowed to crystallize out by boiling with 
from one to four volumes of alcohol. If a heavy precipitate results which sticks 
to the glass, the fluid is simply decanted, but if flocculent, it is filtered through a 
heated filter and then allowed to cool. The fluid then stands for twenty-four 
hours. If inosite is present, crystals will form which may be filtered out and 
washed with cold alcohol. The alcohol precipitate may be dissolved in boiling 
water, from three to four volumes of hot alcohol added, and the above procedure 
repeated to recover the inosite therein contained. If no crystals form, to the 
clear alcoholic filtrate is added little by little ether until a slight milky cloudiness 
results which does not disappear. This is then allowed to stand for twenty-four 
hours. All the inosite is precipitated as mother-of-pearl plates. 



660 



CLINICAL DIAGNOSIS 



In case the urine is examined, it is first precipitated by baryta water and the 
filtrate, after heating, precipitated with PbAc, avoiding an excess. It is allowed 
to stand, is filtered, the precipitate washed, suspended in water, decomposed by 
H 2 S, filtered, the filtrate evaporated. One then proceeds as above. 

Inosite crystallizes in rhombohedral crystals which melt at 225 ° C, are soluble 
in water, 1 : 75, insoluble in alcohol or ether. It does not ferment, nor does it 
rotate the plane of polarization; it dissolves Cu(OH) 2 without reduction, is pre- 
cipitated by PbAc, and does not give crystals with phenylhydrazine. 

Scherer's Test. — A small amount of the precipitate of the crystals is evap- 
orated with nitric acid on a platinum-foil almost to dryness. To the residue are 
added ammonia and one drop of CaCl 2 and the evaporation continued to dryness. 
A beautiful rose color results. The crystals must be pretty pure to give a positive 
test. 

Seidel's Test. — This test is similar to the above with the exception that stron- 
tium acetate is used instead of calcium chloride, and a green color with a violet 
precipitate results. This test is positive if 0.3 mg. of inosite be present. 

Allantoin, (CO) 4 (NH) 3 NH 2 . — This body is found in the 
urine of the new-born child. A slight trace is said to occur in all 
normal urines, and especially those of pregnant women. It occurs in 
some ascitic fluids, in liver cirrhosis, and in certain ovarian cysts. 

The albumin is removed by heat and acetic acid. The fluid is then precipitated 
with HgNOs, the precipitate washed, suspended in water, decomposed with H 2 S, and 
filtered. To the filtrate a little ammonia is added, and the whole evaporated to a 
small volume on the water-bath. The clear fluid is then precipitated with ammonia- 
cal AgNOs. (The precipitate is soluble in excess of ammonia, which must be 
avoided.) This is allowed to stand, the silver salt of allantoin is collected on the 
filter, washed, suspended in water, decomposed with H 2 S, the filtrate evaporated, 
and allowed to crystallize. 

The Loewy method is recommended for the urine. The faintly acid urine is 
precipitated with mercurous nitrate (which is dissolved in as little acid as pos- 
sible plus some metallic mercury), filtered, the precipitate well washed, the filtrate 
is then precipitated with H 2 S, and filtered, the filtrate warmed to drive off this 
gas, MgO then added, and the whole precipitated with AgN0 3 . This precipitate is 
filtered, washed, suspended in water, and decomposed with H 2 S while warm ; the 
filtrate evaporated to dryness, the residue extracted with hot water, and when cold 
precipitated with Hg(N0 3 )2. The precipitate is well washed, decomposed with H 2 S, 
the filtrate evaporated to a concentrated solution, whereupon the allantoin will crys- 
tallize out in glistening prisms, which are odorless, tasteless, soluble in 160 parts of 
cold water, and more in warm, insoluble in absolute alcohol or ether. For its 
identification the silver salts are studied, concentrated solutions being precipitated 
by ammoniacal AgNO:j. This precipitate is soluble in excess of ammonia. The 
white flocculent precipitate on standing becomes granular. If dried at ioo° it 
gives an easy reduction of silver. The silver salt of the allantoin dried in vacuo 
gives on fusion 40.71 per cent. Ag. 

Quantitative Analysis of Serous Fluids. — The method given by Thierfelder 1 
is the one we use and of which we here give an outline. We have tried it on all 
sorts of fluids, and while each step is satisfactory, the routine, as a whole, is not, 
since fluids vary greatly in their composition, and the method hits none exactly. 
If one uses enough of some fluids to obtain a nieasurable amount of certain con- 
stituents, the amount of other constituents may be in such vast amounts as to 
render the whole impossible ; determine these latter with a workable amount, and 
the former are an almost vanishing quantity. Hence it is better to determine each 
substance or group in a special portion. We give the outline of the analysis. 

To from 20 to 50 cc. of the fluid measured or weighed, and freed from the 

1 Hoppe Seyler, Chemische Analyse, 1903. 



BODY FLUIDS 



GG1 



formed elements by filtration, are added from three to four volumes of absolute 
alcohol. This is allowed to stand a few hours, filtered through a weighed filter, 
and washed a little with alcohol. This will be Filtrate I. The precipitate is then 
washed with boiling alcohol, into the same flask with ether, and then again with 
alcohol; these combined are Filtrate II. The precipitate is then washed with boiling 
water thoroughly. Filtrate III. The above precipitate will contain the proteid and a 
few salts, haemoglobin if any be present, but not much of the other pigments. It is 
now washed once in alcohol and dried at 120 0 to constant weight, after the pre- 
cipitate next to be mentioned has been added to it. It is then ashed and the 
weight of the ash subtracted from that of the precipitate, giving the weight of 
the protcids. 

Filtrate I. is evaporated at a temperature not above 6o° C. To this residue is 
then added Filtrate II. The residue and fluid are well mixed and the fluid decanted 
through a dried and weighed paper. It is then washed repeatedly with absolute 
alcohol, then with ether, and decanted each time, but none of the precipitate is 
allowed to get onto the paper (B 3). Onto the residue is now poured Filtrate III., 
the residue well mixed, and then all filtered through the same filter-paper, but into 
another flask from that which has received the above-mentioned decanted fluids. 
The precipitate is now brought on the paper and washed with water. This pre- 
cipitate is dried and added to the above-mentioned proteid precipitate, since it 
contains that amount of proteid which was lost in the first precipitation. The 
watery extract of the above is evaporated in a small weighed porcelain dish in a 
water-bath, dried at no° to 115 0 C. to constant weight, and weighed. 

B. 2. It is burned at a mo-derate heat, ashed, and the weight of the ash deter- 
mined. 

B. 3. The alcohol-ether extract is evaporated on the water-bath at a tempera- 
ture not above 6o° C, dried in vacuo over H2SO4. To the residue is added ether, 
and filtered into a flask through a small paper, washing repeatedly with ether. 
This will contain the urea, sugar, soaps, sodium chloride, fat, lecithin, cholesterin, 
and the cholesterin ester. 

B. 3 a is the residue of the above. This is washed from the beaker and paper 
into a small weighed porcelain dish, evaporated, dried at a temperature from no° 
to 115 0 . fused at a moderate heat, and weighed. 

B. 3 b. The ethereal extract is treated as on page 658. It contains fat, choles- 
terin, lecithin, cholin, etc. 

CEREBROSPINAL FLUID 

The normal amount varies greatly; often from 5 to 10 cc. or more 
may be obtained. The fluid is relatively most abundant in the first years 
of life. It is pathologically increased in certain infectious diseases, in 
meningitis, and always in hydrocephalus and in general paralysis of 
the insane. Coriat found it increased in alcoholic cases (10 to 100 
cc), in dementia prsecox (even 50 cc), and in general paralysis, 
sometimes over 100 cc In senile cases it was even 60 cc. 

In color the fluid is either absolutely limpid or has a slight yel- 
lowish color clue to lutein, the pigment of blood-serum. In subdural 
hemorrhage the fluid may be red, in jaundice a greenish-yellow, while 
the presence of pus will of course give it an opaque yellow color. It 
is also stained by certain drugs, as, for instance, methylene blue. 

In reaction it is normally alkaline, but rapidly becomes acid post- 
mortem. Its reaction varies much, and it is said sometimes even to be 
acid during life, due to lactic acid fermentation. But in as short a 
time as ten minutes after death it has been found acid; as in one 



662 



CLINICAL DIAGNOSIS 



case after epileptiform convulsions, in which case the (inactive) lactic 
acid was said to have been present. Its reaction depends directly 
upon the reaction of the brain-tissue. 

The specific gravity, Coriat states, is from 1007 to 1010 normally 
(Halliburton, 1006 to 1008). In various diseases this varies much, 
and nothing specific has been determined. In general paralysis 1009 
to 1 01 2 are common figures ; in hydrocephalus 1008 to 1009, thus 
within the normal limits. 

In the cerebrospinal fluid is found a reducing body, 0.04 to 0.05 
per cent., the nature of which has been much disputed. Halliburton 
claims that this is similar to pyrocatechin, that it is not sugar, is always 
present, and is increased by repeated tappings. This reducing body 
reduces copper but not bismuth, does not ferment, is optically inactive, 
and gives no osazon with phenylhydrazine. Mott and Halliburton 
found this body absent in twelve of fourteen cases of general paresis; 
it is absent in tuberculous, and especially epidemic, cerebrospinal 
meningitis. Others claim that glucose is present in hydrocephalus 
(Cavazzini) ; in diabetes (Schaefer), in which case 0.32 to 0.35 per 
cent, is said to have been found; in grave pneumonia it is increased. 
Coriat thinks that the body is glucose, or, at least, is not pyro- 
catechin. 

Urea is present but has no pathological significance. The normal 
amount is from 0.0 1 to 0.05 per cent. Much is present in the fluid 
of a case of hydrocephalus ; much in nephritis, even 0.45 per cent., and 
considerable in that of arteriosclerosis. 2 

The proteids found are globulin, nucleo-proteid, and protalbumose. 
The total proteid according to Quincke is from 0.2 to 0.5, Ricker 
0.5 to 1, and Gumprecht 0.25 per litre. Halliburton found globulin 
present in thirteen cases, and in six cases albumose also, while in 
three, two of which were clearly cases of inflammation, albumin was 
also found. No fibrinogen is ever found normally. (To detect this 
a little blood-serum is added to the cerebrospinal fluid, and its presence 
is evinced by fibrin formation.") Serum albumin is said to be normally 
absent. In meningocele albumose and peptone have been found. 

In general paresis the total solids are even 2.39 p. m. ; the proteids 
are considerably increased. There is some increase in hydrocephalus, 
in inflammatory conditions, in cases with stasis due to brain tumor 
(2 to 4 p. m.), after repeated tappings, in apoplexy, and in meningitis 
( as a rule, 2 to 3 p. m. ; but if purulent 7 to 9 p. m.). 

Mott and Halliburton recommend the following quantitative method: The 
fluid is made acid with acetic acid, two volumes of absolute alcohol are added, 
it is then boiled, filtered, the precipitate dried at no° C, and weighed. 

2 See Widal and Froin, Gaz. des Hop., No. 122, 1904. 



BODY FLUIDS 



663 



In eight cases of general paresis the average percentage was 0.239. 
In two of spina bifida 0.088 per cent. In general paresis proteoses and 
peptones were absent and the proteid was chiefly globulin with a little 
nucleoproteid. 

This latter is determined in one litre of the fluid to which alcohol has been 
added, and the precipitate digested in water. If the undissolved residue is found to con- 
tain a high percentage of phosphorus, indicating nuclein, the residue is washed with 
0.2 per cent. HC1, heated on the water-bath at ioo° C. with fuming HNO3 and a 
small amount of H.SCX and KCIO3. The residue is dissolved in HNO3 and am- 
monium molybdate added; a yellowish crystalline precipitate results. 

A very good idea of the amount of proteid present may be gained by the heat- 
acetic-acid test. A normal fluid remains clear on standing some hours. If it be 
boiled no cloud at all results, but on adding a drop of dilute acid a very faint 
white opalescence appears, which will separate in fine rlocculi. It is easy to 
recognize a denser cloud than normal. 

Saline constituents present nothing interesting; they resemble 
those of other serous fluids. 

The toxicity of the fluid has been found increased in general pare- 
sis, also after epileptic seizures. Its poisonous qualities are due to 
cholin and other products of nerve degeneration. 

Cholin is a decomposition product of lecithin, the chief component 
of the myelin sheaths, and is found where there is nerve disintegration. 
It is a body which is soluble in water and alcohol, insoluble in ether, 
is precipitated by PtCl 6 as polymorphous crystals, which, however, if 
recrystallized from warmed 15 per cent, alcohol are regular octahedra. 
These crystals are insoluble in alcohol and ether, but soluble in water. 

The careful technique given by Coriat is as follows : The proteids are first 
precipitated by 95 per cent, alcohol in excess, the filtrate evaporated over the water- 
bath at 40 0 to dryness, extracted with absolute alcohol, filtered again and evap- 
orated to dryness. This process is repeated several times, the temperature always 
being kept low. All traces of proteid and potassium salts are thus removed. The 
final residue after extraction with absolute alcohol is a syrup of a light color, 
which is divided into two parts. The first is dissolved in distilled water, and the 
second in 15 per cent, alcohol. The watery solution is tested for proteid by the 
biuret, Millon, and other proteid reactions, which must all be negative ; for cholin 
by the ordinary reactions for alkaloid (phosphotungstic and phosphomolybdic acids, 
et ah), which must all be positive. To the alcohol solution are then added four 
drops of 4 per cent. PtCle, and this is evaporated in a watch-glass over CaCL. 
For a positive test tannic acid should give no precipitate (thus neurin is ex- 
cluded) ; phosphotungstic acid a white precipitate, phosphomolybdic a yellow, also 
PtCle and AuCl 6 , and Lugol's a brown precipitate. On evaporating the 15 per cent, 
alcohol solution, large yellow octahedral crystals must be formed, easily soluble in 
water (therefore not neurin). Their size, solubility in water, and the fact that 
the watery solution gave the alkaloid reaction, excludes potassium. These crystals, 
if in a sufficient amount, may be dried and the platinum determined, which should 
be 34.8 per cent. 

In the same hydrolysis with lecithin are formed the glycero-phos- 
phoric acids and stearic acid. The latter unites with the glycerol radi- 
cals to form the neutral fats upon which the Marchi stain depends. 



664 



CLINICAL DIAGNOSIS 



The cholin is eliminated in the cerebrospinal fluid and the blood. 
Glycerophosphoric acid is eliminated in the urine. 

The presence of cholin indicates nerve disintegration. It has been 
found, however, in a wide variety of nervous disturbances, general 
paresis, combined sclerosis, insular sclerosis, alcoholic neuritis, beri- 
beri, senile dementia, delirium tremens, et al., roughly in amount par- 
allel to that of proteid present, both being a measure of nerve-tissue 
disintegration. Mott considers that it cannot be used to separate the 
organic from the functional disturbances unless the organic disturb- 
ance be active at the time the fluid is examined. Although it occurs 
in such a variety of cases, its most constant occurrence is in general 
paresis, in which disease Coriat found it present in all of fourteen 
cases, yet with no relation between amount and anatomical findings. 

We add a table of a few analyses we have recently made, calling particular 
attention to the high solid content in stasis (due to brain tumor), and to the dif- 
ference between the ventricular and spinal fluids in a case of hydrocephalus, a 
difference which we had noted in two previous cases. 

The cerebrospinal fluids will not keep, in fact are full of bacteria in a few 
hours ; hence must be used while fresh. 

As regards cholin our experience is limited, but we fail to find the demon- 
stration of octahedral crystals so very easy. 

CEREBROSPINAL AND VENTRICULAR FLUIDS 



5 
6 

7 

8 

9 

TO 
II 



Case. 



Normal child 

Normal child 

Hydrocephalus : 

Cord 

Brain (fluid from) 

Hernia of brain 
(tumor) 

Later 

Later 

(Ventricular 
fluids. ) _ 

Tumor of brain 
(Hernia. ) 

Gunshot wound ; 
head 

Cerebrospinal 
meningitis 

Streptococcus 
meningitis 

Tuberculous men- 
ingitis 

Pneumonia ; men- 
ingeal symptoms.. 

Paresis ? 



5o 
630 
45o 



200 

25 
100 

25 



10 
30 



1007.4 
1008.3 

1002. 
1006.2 



1006.9 
1007.7 



ron. 6 

1009.2 

1007. 

1009.2 

1018.8 

1006. 
1008. 



0.96 



2.5132 



0.0991 

0.170 
0.1 112 



2.664 



0.1628 
0.066 



>9, 

'ZX' 



0.2703 
0.62 

0.5964 



0.7839 



0.5629 



0.0597 



0.507 
0.492 

0.5166 



0.68 



; 6c 
: 3 

I « . 

' 2u 



0.2937 
o.374 



0.1988 



0.4712 0.4112 



0.2092 



0.2445 



0.023 
0.016 



0.0185 



BODY FLUIDS 



665 



Cytodiagnosis of Cerebrospinal Fluid. — A good deal of atten- 
tion has recently been directed to this subject, especially by the French 
for the diagnosis of general paresis, tabes dorsalis, and lues. Widal 
and others have shown that in these conditions, really diseases with 
chronic posterior meningitis and small round-cell infiltration of the 
meninges, there is a lymphocytosis which fails in functional cases and 
in conditions in which the meninges are not infiltrated. In purulent 
infections one will find a predominance of pus-cells. In tuberculosis 
there does not seem to be the same constancy of a lymphocytosis as in 
tuberculosis of the pleura, although if lues can be ruled out a lympho- 
cytosis is said to suggest tuberculosis ( when the clinical symptoms 
point to meningitis) . But it may be due also to any other long-contin- 




L fife 

Fig. I22C. — Smear of the spinal fluid of Fig. 122a. — Smear of the spinal fluid of 

a case of epidemic cerebrospinal menin- a case of meningitis due to Diplococcus 

gitis. lanceolatus. 

ued irritation, as lues, uraemia, tetanus, and mechanically by tumors. 3 
Fischer considers in general paresis the chronicity to be very impor- 
tant, only the acute cases showing a lymphocytosis, the chronic cases 
none. 

To get a fairly correct idea of the number of cells in the fluid the technic must 
be at least uniform. The method of Marie's clinic is as follows : Three cubic centi- 
metres of the fluid are centrifugalized for fifteen, minutes in 15 cc. tubes with very 
sharp points. As much of the fluid as possible is then decanted, and the edge of 
the tube blotted. With a very fine pipette is then taken up the very small drop, all 
that can be collected from the end of the still inverted centrifuge tube. This is then 
spread on a slide as a round area of uniform size about 7 mm. in diameter. This 
is stained with any polychrome methylene blue mixture and examined with the 
400 magnification. A few lymphocytes are normal. An increase can merely be 
estimated by a comparison based on the uniform technic. 

Using technic similar to the above Widal considers 4 or 5 lympho- 



3 Schlesinger, Deut. med. Woch., 1904, No. 28. 



666 



CLINICAL DIAGNOSIS 



cytes per field of the 400 magnification as the maximum normal ; as 
a rule, none are found. 

The method now in use is to count the cells directly in the fresh 
undiluted spinal fluid, using- the ordinary blood counting chamber, 
or, better, one which is 0.2 mm. deep. Normally one finds not over 
5 cells per cubic millimetre. This method gives such reliable results 
that it is now, used as a routine in all doubtful nervous and mental 




Fig. i 22c — Smear of the spinal fluid of a case of meningitis due to Bacillus influenzae. 

cases. Kramer 4 found in general paresis 6 to 145 per cubic millimetre, 
in dementia prsecox o to 2, and in other cases o or 1 cell. 

In cases with stasis (hernia cerebri) occur large cells full of large 
fat-like granules. 

TRANSUDATES AND EXUDATES 

Although the pathologists will not agree, the clinical chemist may 
call a transudate a fluid which is not the result of an inflammation, 
but more of a filtration ; while an exudate is the result of an inflam- 
mation. The transudates resemble lymph, contain few formed elements 
and almost no fibrin. Their proteids are serum albumin, serum globu- 
lin, and a little fibrinogen, yet not enough of the last to coagulate these 
fluids spontaneously, although they will coagulate if blood be added. 
The exudates are richer in formed elements, coagulate spontaneously, 
contain the so-called nucleo-albumin and a mucoid substance. The 
specific gravity varies as the amount of albumin. Some claim that 
that of the transudates varies from 1015 to 1018, and if over 1018 the 
fluid is an exudate. This rule is practically true, and yet often fails. 
The list of extractives which may be present includes urea, glucose, 
creatinin, uric acid, lactic acid, inosite, succinic acid, allantoin ; 
pathologically occur leucin, tyrosin, bile acids and pigments, fat, 
lecithin, and cholesterin. 

This " nucleo-albumin," or better " euglobulin," is valuable in dis- 



4 Am. Jour. Insan., vol. lx. p. 107. 



BODY FLUIDS 



667 



tinguishing these two classes of fluids. If a few drops of acetic acid 
be added to a clear exudate, a cloud of varying depth, but usually 
quite dense, will form. It is rather soluble in excess of the acid. The 
cloud in transudates is very much lighter. 

Peritoneal Fluid. — In cachexia and hydrsemia this fluid is slightly 
colored, of a milky opalescence, does not clot spontaneously, has a 
specific gravity of from 1005 to 1015, and almost no cells. 

In chronic passive congestion the specific gravity is usually lower 
than 1020. Sometimes it contains 35 gms. per litre of proteid. In 
cases of cancer of the peritoneum the fluid is turbid with cells, of a 
dirty grayish appearance, a high specific gravity, and often clots spon- 
taneously. The serous fluid present in inflammations is of a straw or 
lemon-yellow color, somewhat cloudy from the formed elements, coag- 
ulates spontaneously ; proteid 30 gms. or more per litre, and a specific 
gravity of 1030 or above. Mucoid substance is perhaps always 
present. 

This is proven by removing the albumin by heat and then by precipitating 
the filtrate by alcohol. A precipitate is formed from which one can split off a 
reducing body. 

In the ascitic fluid may also be determined urea, uric acid, allantoin, 
xanthin, creatinin, cholesterin, and sugar. 

The fluids we have examined had a specific gravity varying from 1005.5 to 
1019.8, the solids from 1.3 to 4.5 gms. per litre, globulin, 40 to 50 per cent. None 
were very acute cases. 

Pleural Fluid. — Physiologically, there is not enough pleural fluid 
present to be analyzed. The pathological fluid may vary from serous 
to sero-purulent to purulent or hemorrhagic. In hydrothorax the 
specific gravity is lower than 1015 as a rule, the albumin from 10 to 
30 gms. and the fibrinogen hardly 0.1 per litre. In pleurisy the 
exudate has a specific gravity above 1020 as a rule, albumin 30 to 65, 
and the fibrinogen 1 per litre. 

In nine recent cases the specific gravity of the fluids varied from 1012.2 to 
1025.2, and the solids, from 3.12 to 7.926 per cent. The more acute the case the 
higher the figures. The amount of total proteid varied from 2.837 to 6.529 per cent., 
of which from 39 to 64 per cent, was globulin. The amount of globulin depended 
on the acuteness of the case. The acetic acid precipitate was markedly more in the 
acute inflammatory cases than in the transudates. It is interesting what a little 
difference the clotting makes. In a case of acute tuberculous pleurisy, before 
clotting the specific gravity was 1022. 1 and the globulin 2.875 per cent. ; after clotting 
(densely), the figures were 1021.7 and 2.376 respectively. To clear these fluids 
with the centrifuge is better than with Kieselguhr, since the extractions found are 
lower in the latter case. 

The cytodiagnosis of the serous fluids has been a fertile subject 
recently, all work being directed to one point, namely, the possibility 
of a diagnosis of tuberculous pleurisy or peritonitis based on a lym- 



668 



CLINICAL DIAGNOSIS 



phocytosis. Other organisms cause a migration of the polymorphonu- 
clear cells. Concerning the tubercle bacillus there are some who believe 
that the lymphocytosis is an active migration of the small mononuclear 
blood-cells ; others that these cells are really derived from the endo- 
thelial lining of the serosa. 5 It is true that in some cases of so-called 
proliferative pleurisy or peritonitis there are found a great many free 
endothelial cells and large groups in mulberry-like masses in the fluid. 
It is also true that these endothelial cells undergo degenerative changes, 




Fig. 123. — Cells from a pleural exudate, showing the transitions.from large to small cells 
(lymphocytes). X 900. 



the result of which is a cell similar to a lymphocyte ; but in tuberculous 
pleurisy the cells are chiefly typical lymphocytes and the stages of 
condensation of larger cells not so evident. In Fig. 123 we have 
drawn some of the cells from a chronic pleurisy, showing their 
transitions from very large flat to small compact cells. The lympho- 
cytes in the picture seem different. 

These fluids are best examined while fresh, the cells being centrifugalized 
before clotting occurs. Smears are made, and stained with a polychrome-methylene- 

5 See Patella, Deut. Arch. f. klin. Med., April 17, 1902. 



BODY FLUIDS 



669 



blue-eosin mixture. That recommended by Musgrave is Wright's mixture diluted 
with methyl alcohol 3: r. This stain is left on one-half minute, then diluted with 
water for three minutes (see page 459). 

In hydrothorax the cells are few and mainly endothelial ; even in 
the serous stage of pnenmococcus and streptococcus pleurisy there is 
a great preponderance of polymorphonuclears ; in tuberculous inflam- 
mations the lymphocytes are the predominating cell, since the infection 
is weak and long-standing. This is as far as most observers go. 
Others go farther. Barege, for example, says that in the fluid of car- 
diac and Bright's disease, if the fluid contains many endothelial cells, 
few small mononuclears, and fewest polymorphonuclears, the origin 
is mechanical ; a slight increase of the last cells means congestion of 
the lungs, and a considerable polynucleosis means lung infarct. The 
work of 1903 was in favor of cytodiagnosis, but then the pendulum 
swung, and now workers are sceptical. 6 

A study of cases from this clinic was made by Bunting." 

The exceptions to such rules are too numerous. Some find lympho- 
cytosis in transudates, in pneumococcus, influenzal, and staphylococcus 
infections ; and polynucleosis when strictly there is no inflammation, as 
in infarcts, sunstroke, and cancer. Some called the findings " rela- 
tive," others said " problematical." We use cytodiagnosis very little 
now, since it is easier to find the organisms themselves, and if we find 
them we are certain. 

In some cases Mastzellen are greatly increased. In tuberculous 
pleurisy there is a slight eosinophilia (2 to 5 per cent. ) , in acute pleurisy 
sometimes a high eosinophilia (of 10 to 74 per cent.) which means a 
good prognosis. 

The possibility is always present of diagnosing cancer of the pleura 
or peritoneum by the cells of the fluid, 8 and especially by the small 
mass sometimes found sticking to the end of the needle. 

Inoscopy is the method proposed by Jousset 9 for isolating the tubercle bacilli 
from exudates. The fluids were allowed to coagulate spontaneously, or a little 
horse serum added which produced this result. The clot is digested, the resulting 
fluid centrifugalized, and smears made and stained for tubercle bacilli. The clot 
will have caught most of the organisms. It is first pressed out, then torn into 
fragments and mixed with a fluid consisting of pepsin, 1 to 2 gms., glycerin, 10 cc. ; 
HC1 40 per cent., 15 cc. ; NaF, 3 gms.: water, 1000 cc. Jousset claimed that di- 
gestion took but three or four hours. He obtained astonishingly good results, so 
good that his critics hint that he mistook masses of haemoglobin or fuchsin and 
scratches on the glass, etc., for tubercle bacilli (Kormoczi and Jassinger). 

The fluid may be centrifugalized while very fresh, or injected into a guinea- 
pig. We have not had good success with inoscopy. 

6 See especially Miller, Am. Med., November 12, 1904. 

7 J. H. H. Bull., July, 1903. 

9 La Sem. Med., No. 3, 1903. 

s Steiner, J. H. H. Bull., October, 1901. 



670 CLINICAL DIAGNOSIS 

Pericardial Fluid. — This fluid normally is of a lemon-yellow color, 
slightly viscid, and seems to contain more fibrin than other physio- 
logical fluids. The solids are from 37.5 to 44.9 gms. per litre; albu- 
min, 22.8 to 24.7; soluble salts, from 8 to 9; insoluble salts, 0.15; 
extractives, 2 per litre. 

The fluid of a recent case had a specific gravity of 1020.4; solids, 5.8 per cent.; 
total proteid, 3.91, and globulin only 15.2 per cent, of this. 

Synovial Membrane. — The fluid is alkaline, thick, sticky, viscid, yel- 
lowish in color, cloudy often from the cell detritus, or clear. It con- 
tains albumin, salts, and a body which is physically like mucin, but 
which cannot be, since no reducing body can be split off. Neither is it 
nucleo-albumin. Salkowski has given it the name " synovin." 

The fluid from a recent case of rheumatism, and which clotted firmly, had a 
total proteid content of 4.3 per cent.; water-soluble extractives, 1.07 (ash. 0.606) 
per cent.; alcohol-ether-soluble extractives, 0.076 (ash, 0.046) per cent.; fat fraction, 
0.35 per cent. 

Chylous Fluids. — Fluids which are milky in appearance have always 
attracted considerable attention. Sometimes a fluid may be truly chy- 
lous, in which case from 3.86 to 10.3 per litre of fat are often obtained, 
and in Minkowski's case from 17 to 43 per litre. Such fluids clear 
on shaking out with ether. In other cases, however, the fluid does not 
contain nearly enough fat to explain the turbidity. By some lecithin 
is supposed to explain the cloudiness, but other fluids with much lecithin 
are clear and some milky fluids have very little (Christen). Others 
consider that globulin explains it, or casein or seromucoid. The most 
recent explanation is that it is a compound of globulin and lecithin, 
whether in combination or not is uncertain. Bernert, who examined 
one case with exceeding care, sums the matter up as follows : There 
are cases in which the milkiness is not due to fat alone, but to albumin 
of the globulin group from which large amounts of lecithin can be 
extracted by hot alcohol. The fat content is low, and resembles that 
of the so-called fatty degeneration of the epithelial cells. Quincke 
first showed that albumin also in fine granules could give a milky 
appearance. 

The color of such fluids is white or yellowish-white, greenish or 
reddish, opalescent in thin layers. Some fluids become more milky on 
cooling. In some cases a perfectly clear fluid on the first tapping 
becomes progressively more milky on the subsequent tappings. On 
standing the fluid will sometimes deposit a sediment and have a well- 
marked cream on the surface. Filtering or centrifugalizing does not 
clear it. The specific gravity varies from 1010 to 1014. In one case 
it was 1 06 1, in another 1081, in which cases much pus must have been 



BODY FLUIDS 



671 



present. Their reaction is alkaline, and, strange to say, there is no 
odor. In the cases that we have examined this has been a marked 
feature. They are very resistant against decomposition, and the 
fluids could remain in the laboratory for weeks without apparent 
change. The sediment is slight, consisting of epithelial cells, all 
degenerated with fatty globules, and globules which do not take the 
stains of fat. 

In general there are two classes of cases, — those very milky, the " chylous," 
and the " chyliform," which are only very opalescent. In this case we used the 
terms only as descriptive without implying that chyle was or was not present. 

The former occur when chyle is present, as in the traumatic cases; in others 
the fat may best be explained by the fatty globules freed from the fatty degenerated 
epithelium cells. But the majority of cases are hard to explain. Our best case 
was one of tuberculosis of the peritoneum. In Tabora's case of peritonitis carci- 
nomatosa the fat was 1.2 per cent.; sugar, 0.864 per cent. 

In our case of markedly chylous ascites the specific gravity was 1013.3 ; proteid, 
5.1 14 gms. per litre; globulin, 73 per cent, of this. The fat-cholesterin-lecithin- 
fraction 1.469 per cent. 

The opalescent fluids occur in a great variety of conditions, and are often 
found at autopsy ; cachexias, anaemias, heart cases, etc. ; Naunyn stated that the 
cause in many cases is amyloid degeneration of the blood-vessels of the serosa. 
The reason suggested for chylous fluids in cases of heart-failure is stasis in the 
thoracic duct. In other cases the stasis may be due to the pressure of tumors on 
the duct. 

A chyliform ascitic fluid from a case of uraemia had a specific gravity of 1005.5, 
and solids 1.2988 per cent. 

OVARIAN CYSTS 

Colloid is not one substance, the name being based on the physical properties of 
the contents of various cysts and organs. They are gelatinous, insoluble in water 
and acetic acid, soluble in alkali. From some may be split off a reducing body, but 
their composition varies much. 

Pseudomucin (Metalbumin). — This body occurs in many ovarian cyst con- 
tents which are very viscid and slimy. Alcohol gives a thready precipitate 
resembling wood-pulp, which can be wound around the rod. It is not precipitated 
by heat nor by acetic acid. The precipitate formed by alcohol is ground fine under 
alcohol, and then freed from alcohol by means of ether, and dissolved in water. 
It is then reprecipitated with alcohol. A light white powder is obtained which is 
soluble in water to an opalescent mucoid solution, which is not well precipitated 
by acetic acid. When boiled with HC1 an abundant reducing body is split off, 
which reduces copper very easily. 

Paramucin. — This is a substance present in certain ovarian cysts, also in the 
ascitic fluid providing the ovarian cyst has already ruptured into the abdomen. It 
is firm, glistening, with the consistency of gelatin, soluble in dilute mineral acid, 
shrinks in acidulated alcohol, or in alcohol and ether, and can be reduced to a 
fine white powder. Its characteristics are, its insolubility in water, the fact that it 
swells in alkali dissolving in excess, that it is precipitated by acetic acid and is 
soluble in excess, and, especially, that it will reduce copper salts without preliminary 
boiling with acid. 

Serous Cysts (dilatation of Graafian follicles) contain a perfectly 
clear serous fluid, watery, which foams easily, is of amber color, of a 
specific gravity from 1005 to 1022 (usually 1005 to 1014), with solids 
from 10 to 40 per litre and all the other constituents of serous fluids. 



672 



CLINICAL DIAGNOSIS 



In two recent eases the specific gravity was 1022 in one case, 1016 
in another ; they contained a great deal of albumin. Heat alone caused 
but a faint cloud, but one drop of acid made the fluid perfectly solid. 
Both serum globulin and serum albumin were present ; in these little 
or no euglobulin. 

Proliferating Cysts from Pfluger's Tubules. — The contents of these 
are various. Some contain " colloid," and on boiling with acid give a 



1 ■ ■ ' ' 1 



I ' " ■ .J 

Fig. 124. — Fatty acid crystals from the contents of an ovarian cyst. X 400. 

reducing body. From the colloid ovarian cysts the fatty crystals 
(soluble on warming) may be watched to crystallize out singly and in 
rosettes (see Fig. 124). 

Another group of cysts contain a viscid fluid, very stringy, which 
varies much in consistency according to the amount of serous fluid 
present. It is of a brownish or dark greenish-brown color. 

The specific gravity of the contents in three recent cases was 1025 to 1030.2 ; 
the solids were 9.7 and 9.3 per cent. ; the alcohol precipitate, 6.9 and 8.5 per cent. 

Some, however, contain a thin watery fluid, of a bluish-white opal- 
escent color which may, however, be yellowish, yellowish-brown, or 
greenish, according to the amount of blood present. 

We give a few examples of the contents of such cysts which we have recently 
seen. 



BODY FLUIDS 



673 



1. Fluid quite opalescent; specific gravity, 1004.3; solids, 2.837 per cent. Alco- 
hol precipitate 1.98 per cent, resembles macerated filter paper, is not stringy, can 
be reduced to a fine white powder, difficultly soluble in water to an opalescent 
fluid. Watery extractives 0.524 (ash. 0.388) per cent. Alcohol-ether soluble ex- 
tractives, 0.2056 (ash, 0.108) per cent.; fat, cholesterin, etc., 0.96 per cent. 

2. Fluid reddish-yellow, considerable sediment of small epithelial and some 
large epithelial cells with coarse refractile granules ; filters clear. Specific gravity, 
1008.04 ! solids, 2.32 per cent. Alcohol precipitate similar to above. 

3. Bluish opalescence ; specific gravity, 1007.3. 

Of some of the multilocular cysts the contents are thick, not espe- 
cially viscid, but a suspension of glistening masses of cholesterin crys- 
tals and of a yellow-red or brown color, depending on the blood 
pigment. 




Fig. 125. — Cholesterin crystals. X 400. 

Of a recent case the figures were, specific gravity, 1025.9. The alcohol precipi- 
tate, 10.56 per cent., contained no reducing body. Half saturation of the original 
filtered fluid with (NH^SO* gave a precipitate 0.692 per cent, (globulin?) ; albu- 
min? 0.604 per cent. Extractives, soluble in water, 1.46 (ash, 0.266) per cent.: 
alcohol-soluble extractives, 0.56 (ash, 0.44) per cent. Microscopically a great 
amount of detritus in the sediment, with very large cells (epithelial) full of 
glistening granules, cholesterin crystals, and fat needles. 

In another similar case the specific gravity of the fluid was 1030.6. 

The sediments contain much detritus, red blood-cells, leucocytes, 
large epithelial cells, single and in groups, filled with granules like fat, 
large masses of fatty granules, cholesterin crystals, and colloid gran- 
ules which are large, circular, strongly refractive bodies. 

In the case of a dermoid, the contents of which contained much paramucin, 
serum globulin and albumin could also be demonstrated. Water content of the 
jelly, 92.2 per cent. The alcohol precipitate in one case was 3.3 per cent. Water- 
soluble extractives, 0.4 (ash, 0.27) per cent. Alcohol-ether extractives, 0.25 (ash, 
0.16) per cent. 

Tubo-ovarian Cysts. — The contents of these are watery, thin, serous, 
and contain no pseudomucin. 

Parovarian Cysts. — These contain a thin watery fluid of a very pale 
yellow or colorless or slightly opalescent appearance. Specific gravity, 
1002 to 1009; solids from 10 to 20 per litre; no pseudomucin. Albu- 
min may fail entirely or be only slight in amount. It consists, there- 
fore, of water and extractives. 
43 



674 



CLINICAL DIAGNOSIS 



In a recent case, age twenty years, the cyst contained about 2 litres of very 
clear watery fluid with very slight opalescence; specific gravity, 1007.8; only the 
faintest precipitate with alcohol or ammonium sulphate; chlorides, 0.45 per cent, 
(as NaCl). Microscopically there were very few epithelial cells, round, granular, 
with a round nucleus. 

Intraligamentous Cysts. — The contents of these are yellow, yellowish- 
green, or brownish. They contain little or no pseudomucin ; specific 
gravity, 1032 to 1036 ; solids, 90 to 100 per litre, and the proteids of 
the blood plasma. 

Hydrocele. — The contents are of a high color, clear or dark yellow, 
or greenish; specific gravity, 1014 to 1026; the solids on an average 
of 60 per litre. The fluid sometimes coagulates spontaneously. Leu- 
cocytes are always present, sometimes cholesterin crystals. 

For illustration, in one case the specific gravity was 1010.7; solids, 6.329 per 
cent. ; total albumin, 5.92 per cent, of which 45 per cent, was globulin ; water- 
soluble extractives, 0.7504 (ash, 0.462) per cent; alcohol-ether extractives, 0.452 
(ash, 0.1726) per cent.; fat fraction, 0.1864 per cent 




Fig. 126. — Sodium biurate crystals from a tophus. X 400. 

Spermatocele. — The fluid of these cysts is colorless, watery, slightly 
milky; specific gravity, 1006 to 1010; average solids, 13 per litre; 
proteids slight, containing cell detritus, fat granules, and spermatozoa. 

Tophus. — The tophi of gout, so important in diagnosis, can only 
be distinguished from small sebaceous cysts, small cartilaginous tu- 
mors, etc., by the microscopic examination of their contents. A little 
is mixed with water and found to be an amorphous paste, with many 
needles of sodium biurate (Fig. 126). Amorphous sebaceous matter 
with many fatty and cholesterin crystals is in sebaceous cysts. 

The masses of urea crystals, the " urea frost," which appear on 
the skin of the face in rare cases of nephritis just before death (there 
have been but five cases in this clinic) may be tested by the method 
given on page 117. This is a most interesting phenomenon. The 
circulation in the skin is so poor when it occurs that it is very hard to 
believe that the immediate source of the urea is the blood. 



INDEX 



A 

Abscess, leucocytes in, 529 
of kidney, blood in, 529 
of liver, blood in, 620 

sputum in, 77 
of lung, leucocytes in, 529 
sputum in, 76 
Absolute amount of HCL in 

gastric juice, 349 
Absorption power of stomach, 
364 

Accidental albuminuria, 228 
Aceto-acetic acid, 195 
Acteone, quantitative deter- 
mination of, 195 

in the urine, 190 
Acholic stools, 388, 390 
Achylia gastrica, 373 
Acid, alloxyproteinic, 128 

chrysophanic, 103 

diacetic, in urine, 195 

ferments, 164 

glycuronic, 205 

hippuric, 256 

homogentisinic, 207 

hydrochloric, 129, 343 

lactic, 357, 378, 659 

nitric, 143 

nitrous, 144 

oxalic, in urine, 255 

oxybutyric, 198 

oxyproteinic, 128 

phosphoric, 133 

silicic, 143 

sulphocyanic, 143 

sulphuric, 138 

thiosulphuric, 143 

uric ,117 

uroleucinic, 207 

values, 393 
Acid-fast bacteria, 51 
Acidity of gastric juice, 343 

of urine, 103; determina- 
tion of, 107 

organic, in gastric juice, 
360 

total, of gastric juice, 343 
values, 393 
Acidophilic, cells 502 

leucocytes, 502 
Acidosis of diabetes, 203 
Acids, bile, in stool, 390 
in urine, 158 
fatty crystals, in sputum, 
31. 33 

inorganic, of urine, 129 
Acromegaly, blood in, 609 
Actinomycosis of lung, spu- 
tum in, 42 
Acute articular rheumatism, 
blood in, 604 
bronchitis, 67 
diffuse nephritis, urine 

in, 311 
diseases, blood in, 590 
lobar pneumonia, spu- 
tum of, ss 
luetic nephritis, urine in, 
313 

Acute miliary tuberculosis, 
blood in, 598; sputum 
in, 46 

nephritis, urine in, 311 
nephritis of cholera, urine 

in. 3i3 
parenchymatous nephri- 
tis, 311 



Acute pneumonic tuberculosis, 

46 

yellow atrophy of liver, 
blood in, 622 
Addison's disease, blood in, 

602, 621 
Adenin, 123 

Adenitis, tuberculous, blood 
in, 590 

Adolescence, albuminuria of, 

228, 229, 232 
Adrenals, tuberculosis of, 

blood in, 599, 621 
^Estivo-autumnal malaria, 

parasite of, 628, 636 
Agar media, 287 
Age, effect of, on count of 

reds, 484 
Agglutination phenomena, 470 
Agglutinins, 651 
Agonal leucocytosis, 531 
Air in sputum, 22 
Albumin, calculi of, 282 

determination of, in body 
fluids, 657 

in stools, 397 

quotient, 217 

serum, 217 

tests in urine, 208 

to remove from urine, 217 
Albuminous expectoration, 79 
Albuminuria, 217 

accidental, 228 

adolescence, 228, 229, 232 

after baths, 227 

alimentary, 227, 239 

anaemia due to, 558 

cyclic, 228, 230 

due to Bright's disease, 
234 

due to definite renal le- 
sion, 234 

due to palpation of kid- 
ney, 233 

essential, 228 

false, 224 

febrile, 233, 310 

functional, 225 

haematogenous, 233 

hereditary, 232 

hypostatic, 232 

intermittent, 228, 232 

luetic, 235, 313 

minima, 232 

nervous, 234 

of apparently healthy, 
228 

of diabetes, 204 
of labor, 228 
of masturbators, 229 
of new-born, 21 
of puberty, 228 
orthostatic, 228, 230 
orthotic, 228 
physiological, 228 
post-infectious, 232 
postural, 228, 230 
structural, 225 
traumatic, 233 
true, 224 

without definite renal le- 
sion, 224 
Albuminuric cicatricielle, 232 

paracellaire, 232 

phosphaturique, 232 

pregoutteuse, 232 

residuale, 232 
Albumosuria, 235, 237 



Albumosuria, alimentary, 239 

enterogenous, 239 

febrile, 239 

haematogenous, 239 

hepatogenous, 239 

myelopathic, 235 

pyogenic, 239 
Alimentary albuminuria, 227 
239 

albumosuria, 239 

chloruria, 33 1 

levulosuria, 185 
Alkaline tide, 105 
Alkalinity of blood, 544 

Moore and Wilson's 
method, 546 
Alkaptonuria, 206 
Allantoin, 660 
Alloxuric bases, 122 
Alloxyproteinic acid, 128 
Almen's test for glucose, 171 
Aloin test, 395 

Altitude, effect of, on count 

of reds, 486 
Alveolar epithelial cells in 

sputum, 27 
Alymphaemic lymphomatosis, 

534 

Amboceptors, 651 
Ammonia in gastric contents, 
360 
in urine, 123 
Ammonium biurate, 249 

magnesium phosphate, 251 
Amoeba coli, 402 
mitis, 403 
pulmonalis, 43 
vulgaris, 404 
Amoebic dysentery, anaemia 
due to, 557 
stools in, 424 
Amount, absolute, of HC1 in 
gastric juice, 349 
of sputum, 18 
of urine, 91 
Amyloid kidney, urine in, 316 
Anaemia, 547 

chlorotic, 549 
consumptive, 549 
due to acute gastritis, 557 
due to acute hemorrhage, 

due to acute infections, 557 
due to albuminuria, 558 
due to amoebic dysentery, 
557 

due to bad air, 556 
due to blood poisons, 554, 
560 

due to Bothriocephalus 
latus, 559 

due to chronic gastritis, 
557 . 

due to chronic hemor- 
rhage, 553 

due to chronic infectious 
diseases, 557 

due to coal-tar products, 
561 

due to constipation, 557 
due to diarrhoea, 556 
due to dilated stomach, 
557 

due to dysentery, 556 
due to dyspepsia, 557 
due to fever, 558 
due to gastro-intestinal 
disorders, 556 

675 



676 



INDEX 



Anaemia, due to intestinal para- 
sites, 559 
due to lack of sunlight, 

556 

due to lead, 560 
due to poisons, 560 
due to poor food, 555 
due to pus formation, 

558 

due to Strongyloides in- 

testinalis, 559 
due to ulcerative colitis, 

557 

due to uncinariasis, 559 
due to yellow fever, 560 
hypoplastic, 549 
of children, 606 
of growth, 606 
of the poor, 555 
of the Tropics, 557 
primary pernicious, 549, 
561 

pseudoleukaemica infan- 
tum, 607 
secondary, 549 
simple primary, 561 
splenic, 56 1 
Anaemic degeneration of cells, 
479 

Anaglycosuria, 334 
Analine gentian violet, 285 
Ancestral corpuscles, 517 
Angioneurotic haematuria, 241 
Anguillula aceti in urine, 306 

intestinalis, 415 

stercoralis, 415 
Animal gum, 190 

parasites in sputum, 43 
in stools, 402 
in urine, 304 
Ankylostomum duodenale, 41 1 
Anopheles mosquito, 633 
Anthracosis, 21, 83 
Antibodies, 651 
Antigens, 651 
Antitoxins, 651 
Anuria, 94 

Appearance, general, of urine, 
90 

Appendicitis, blood in, 605 
Arabinose in urine, 187 
Arsenic in urine, 146 
Arteriosclerosis of kidney, 

urine in, 315 
Arthritis deformans, blood in, 

605 

Arthus and Huber method 

(trypsin), 384 
Ascaris lumbricoides, 408 

texana, 408 
Ascitic fluid, cyto-diagnosis cf, 

666 

Aseptic condition of stomach, 
3 4o 

Asiatic cholera, stools in, 422 
Aspergillus flavus, 39 

fumigatus in sputum, 39 

niger, 39 

subfuscus, 39 
Assimilation limit for sugars, 
165 

Asthma, blood in, 605 

eosinophilia in, 535 

sputum of, 63 
Atony of stomach, 365 
Atrophy, acute yellow, of 
liver, blood in, 622 

of mucosa, 373 

renal, 318 
Avirulent diphtheria bacillus, 
84 

Azotorrhcea, 397 

B 

Bacillus aerogenes capsulatus, 
290 

alkaligenes, 290 

bifidus, 420 

buccalis maximus, 36 



Bacillus coli communis, 288 

diphtheriae, 83 

fusiformis, 88 

Kauffman's, in gastric 
juice, 380 

of influenza, 61 

lactis aerogenes, 289 

paratyphosus, 289 

pseudodiphtheriae, 84 

pyocyaneus, 290 

tetani, 291 

tuberculosis, 49 

typhosus, 289 

ulceris cancroci, 302 
Bacteria, acid fast, 51 

media for, 287 

in sputum, 35 

stains for, 284 

in stomach, 363 

in stools, 386 

in urine, 292 
Bacteriology, of blood 468 
Bacteriolysins, 651 
Bacteriorrhcea, 300 
Bacteriuria, 296 
Balantidium coli, 407 
Bases, alloxuric, 122 

inorganic, in urine, 129 

nuclein, 122 

of gastric juice, 360 

purin ,122 

xanthin, 122 
Basophile granules in red 
cells, 481 
of leucocytes, 504 
Basophilia, 478 
Baths, albuminuria follow- 
ing, 227 

effect of, on red count, 
487 

Bence- Jones's body, 235 

Benedict's method for deter- 
mination of glucose, 178 

Bial's test for pentose, 188 

Bile acids in stools, 390 
in urine, 158 
in vomitus, 339 
pigments in urine, 152 
stained sputum, 20 
tests for in urine, 154 
to remove from urine, 157 

Bilharzia eggs in urine, 305 

Bilifuscin, 152, 153 

Biliprasin, 152, 153 

Bilirubin in stools, 389 
in urine, 152, 157 
in urine sediment, 256 

Biliverdin, 152, 153 

Bismuth crystals in stools, 

^ 399 

Bmrate of ammonia, 249 

Biurates, 119 

Biuret test, 117 

Black's method, qualitative 
determination of 
oxybutyric acid, 

I98 - • 
quantitative deter- 
mination of oxybuty- 
ric acid, 199 
Black urines, 102 
Blackwater fever, 242 
Bladder stones, 280 

tuberculosis of, 294 
Blood, 426 
agar, 288 
alkalinity of, 542 
bacteriology of, 468 
chemical tests for, 243 
examination, value of, 
622 

freezing point of, 326 
fresh, study of, 323, 325 
in abscess of liver, 620 
in acromegaly, 609 
in acute articular rheu- 
matism, 605 
in acute diseases, 590 
in acute yellow atrophy, j 
622 I 



Blood, in Addison's disease, 
599. 621 

in appendicitis, 605 

in arthritis deformans, 

605 

in bronchial asthma, 605 
in bronchopneumonia, 
604 

in cancer, 610 

of breast, 613 
of intestines, 615 
of oesophagus, 614 
of rectum, 615 
of stomach, 613 
of testicle, 615 
in catarrhal jaundice, 620 
in cholangitis, 620 
in cholecystitis, 620 
in chorea, 608 
in chronic diseases, 608 
in chronic septicaemia, 
593 

in cirrhosis of liver, 620 
in depressive insanity, 
609 

in diabetes mellitus, 609 
in diphtheria, 595 
in diseases of liver, 620 
in gall-stone colic, 620 
in general paresis, 608 
in German measles, 594 
in heart disease, 621 
in leprosy, 621 
in lues, 615 

in lues, congenital, 607 

in malaria, 590 

in malignant disease, 610 

in measles, 594 

in myxcedema, 622 

in nephritis, 620 

in nervous diseases, 608 

in pneumonia, 601 

in renal diseases, 618 

acute nephritis, 618 
bilateral cystic kid- 
ney, 620 
chronic nephritis, 619 
in rickets, 608 
in sarcoma, 615 
in scarlet fever, 595 
in scurvy, 622 
in septicaemia, 593 
in smallpox, 595 
in summer diarrhoeas, 608 
in toxic jaundice, 620 
in tuberculosis, 596 

acute miliary, 598 

of adrenals, 599 

of bones and joints, 

599 . 
of intestines, 599 
of lungs, 597 
of meninges, 599 
of peritoneum, 599 
renal, 599 
in typhoid fever, 599 
in typhus fever, 594 
reaction of, 542 
red cells of, 429, 475 
tests for Almen's, 244 
guaiac, 244 
haemin, 244 
Heller's, 243 
Schonbein's, 244 
spectroscopic, 245 
Teichmann's, 244 
Blood-casts, 270 
Blood-cells in gastric contents 
of cancer of stomach, 
38i . 
in gastric juice, 363 
in sputum, 29 
in stools, 394 
in urine, 240 
in vomitus, 339 
Blood-clots in stomach, 381 
Blood-crises, 513. 566, 568 
Blood-cultures, 468 
Blood-platelets, 538 
Blood-serum, Loffler's, 83 



INDEX 



G77 



Blood-smears, 452 
Blood-staining, 456 
Blue, indigo, 148 

urines, 96 
Boas bacillus (Oppler), 3S0 

evening meal, 366 

meal (free lactic acid), 358 

method (lactic acid), 359 
Bodies, foreign, in sputum, 
26 

Bogg's methods for preserving 

and mounting worms, 425 
Bone marrow, 511 

diseases of, eosino- 
philia, in 534 
Bones, tuberculosis of, blood 

in, 599 
Bothriocephalus latus, 418 

cause of anaemia, 559 
Bouillon, 288 
Bound HC1, 347 
Bradyuria, 205 

Brandenburg's method (alka- 
linity cf blood), 545 

Breakfast, test, 341 

Breast, cancer of, blood in, 
613 

Bremer's blood test, 610 
Blight's disease, albuminuria 
of, 234, 3°9 
blood in, 618 
Brodie-Russel coagulometer, 
465 

Bronchial asthma, blood in, 
535. 615 

catarrh, desquamative, 67 

colic, 26 
Bronchiectasis, 73 

hemorrhage in, 74 
Bronchiolitis, 25 
Bronchitis, acute, 67 

capillary, 69 

chronic, 69 

croupous, 72 

eosinophiles in, 27 

fetid, 71 

fibrinous, 72 

plastic, 72 
Bronchoblenorrhcea, 71 
Bronchopneumonia, blood in, 
604 

sputum of, 61 

tuberculous, sputum of, 47 
Bronchorrhcea, 71 

humidum, 71 

serosa, 71 
Buccalis maximus, bacillus, 
36 , 

Buerger s capsule stain, 60 
Butyric oxy-acid in urine, 198 

c 

Cachexia, effect of, on red 

count, 487 
Calcium carbonate sediments, 
252 

of urine, 144 

oxalate crystals in spu- 
tum, 34 
phosphate sediments, 252 

stones, 282 
sulphate sediments, 256 
urate sediments, 250 
Calculosa, pseudophthisis, 25 
Calculus, renal, 280 

leucocytes in, 529 
ureteral, 321 
Cancer fragments in gastric 
juice, 380 
in urine, 278 
of breast, blood in, 613 
of intestines, blood in, 
^624 

of kidney, urine in, 319 
of lung, sputum of, 82 
of oesophagus, blood in, 
614 

of rectum, blood in, 615 
stools in, 423 



Cancer, of stomach, blood in, 
613 

blood in gastric con- 
tents, 381 
flagellates in, 382 
gastric juice in, 376 
of testicle, blood in, 615 
Capillary bronchitis, 69 
Capsule stains, 59 
Carbohydrates in stools, 397 
in urine, fermentable, 165 
unfermentable, 
200, 206 
Carbolfuchsin, 88, 285 
Carbol-thionin stain, 460 
Carbonates in sediments, 251 

in urine, 143 
Carbon-monoxide poisoning, 

effect of, on red count, 488 
Cardiac disease, blood in, 621 
Carnin, 122 
Casts, 269 

blood, 270 
chemistry of, 274 
colloid, 270 
combined, 272 
diagnostic importance of, 
274 

epithelial, 268 
fatty, 269 

fibrinous, in sputum, 24 
glassy, 270 
granular, 268 
hyaline, 270 
of moulds in sputum, 24 
origin of, 273 
prostatic, 308 
pus, 270 
size of, 272 
staining, 276 
testicular, 277 
urate, 272 
waxy, 269 
Catarrh, desquamative of, 

bowel, 400 
desquamatory, bronchial, 

67 
dry, 70 
sec, 70 

Catarrhal jaundice, blood in, 
620 

pneumonia, desquama- 
tory, 28 
Catheterization, technic, 283 
Cavity formation in tubercu- 
losis, 54 
Cells, epithelial, in prostatic 
fluid, 307 
in urine sediment, 
265 

Centrifugalization of urine, 284 
Centrifuge, quantitative de- 
termination of albumin, 216 
Cercomonads in sputum, 43 

in urine, 304 
Cercomonas coli, 405 

hominus, 407 

intestinalis, 405 
Cerebrospinal fluid, 665 

meningitis, lencocytes in, 
526 

Cestodes, 416 
Chalicosis, 21, 83 
Chancres, organisms of, 302 
Character of sputum, 19 
Characteristics of urine in 

general, 90 
Charcot-Leyden crystals in 
blood, 581 
in sputum, 34, 66 
in stools, 399 
Chemistry of casts, 274 
Child, eosinophilia of, 534 
Children, anaemia of, 606 

sputum, of 18 
Chloride, excretion in urine, 
129 

Chloroma, 21 
Chlorosis, 573 
Chlorotic anaemia, 549 



Chloruria, alimentary. 331 
Cholangitis, blood in, 620 
Cholecyanin, 152, 153 

test for bile, Stokvis, 156 
Cholecystitis, blood in, 620 
Cholera, acute nephritis of, 
313 

Cholera spirillum, 422 

leucocytes, 527 
Cholera infantum, blood in, 
608 

Cholesterin in sputum, 34 

in stools, 399 

in urine sediment, 257 
Cholesterinuria, 257 
Choletelin, 152, 154 
Cholin, 663 
Chorea, blood in, 608 
Chromogens, color due to, 21, 
„ 35 

Chronic bronchitis, 69 

diseases, blood in, 608 
gastritis, 371 

interstitial pneumonia, 

sputum of, 61 
nephritis, 313 
passive congestion of 
lung, sputum of, 79; 
urine in, 310 
ulcerative tuberculosis, 
sputum in, 47 
Chrysophanic acid in urine, 
103 

Chyliform fluids, 671 
Chylous fluids, 670 
Chyluria, 263 

Cicatricielle albuminuric, 232 
Cimaenomonas hominus, 400 
Cirrhosis of liver, blood in, 
620 

Clay-colored stools, 388, 390 
Cleaning glass, 427 
Clots, blood, in gastric juice, 
381 

Cloudy swelling of kidney, 

urine in, 310 
Coagula of albumin in stools, 

397. 

of fibrin in sputum, 24 
Coagulation of blood, 464 
Coal pigment in sputum, 21, 

28 

Coal-tar products, anaemia, 

due to, 561 
Coefficient of Ha-ser, 97 
Colic, bronchial, 26 
Colica mucosa, 394 
Colitis, anaemia due to, 557 
Collection of urine, 90 
Colloid casts, 270 
Colon bacillus, 288 
Color index of blood, 500 

of sputum, 19 

of stools, 388 

of urine, 97 

due to medicines, 102 
Coma, diabetic, 203 

leucocytes in, 529 
Combined casts, 272 
Complements, 651 
Complement, fixation of, 651 
Concretions, 280 

acid calcium phosphate, 
281 

albumin, 282 
ammonium urate, 280 
calcium carbonate, 281 

oxalate, 281 
cystin, 281 
fatty, 282 
in bowel, 401 
indigo, 282 
phosphate, 281 
renal, 280 

table for detection of, 282 
triple phosphate, 281 
uric acid, 280 
vesical, 280 
xanthin, 281 
Conductivity, electrical. 329 



678 



INDEX 



Congenital cystic kidney, 319 
heart disease, effect of, 
on red count, 488 
Congestion, chronic, passive, 
of lung, 81 
urine in, 3 10 
Consistency of sputum, 19 

of stools, 386 
Constipation, 387 

anaemia, due to, 557 
latent, 384 
Constituents of normal stools, 
386 

Consumptive anaemia, 349 
Contents of stomach, exami- 
nation of, 338 
Continuous secretion, 368 
Corpora amylacea in prostatic 

fluid, 307, 308 
Cough, whooping, sputum of, 
63 

Counting red cells, 438 
Creatinin, 126 
Crenated red cells, 433 
Crescentic bodies in red cells, 
43 4 

Crises, blood, 513, 566, 568 
Croupous bronchitis, sputum 
in, 72 

pneumonia, blood in, 601 
sputum, of 55 
Cryoscopy of urine, 323 

of blood, 326 
Crystals, Charcot-Leyden, in 
blood, 581 

in sputum, 34 
in stools, 581 
fatty acid, in sputum, 31, 
33 

in gastric juice, 362 
in sputum, 33 
in stools, 398 
melting point, determi- 
nation of, 174 
spermin, in prostatic 
fluid, 308 
Cultures of blood, 468 
Culture media, 287 
Cultures of throat, 83 

urine, 283 
Curds in stools, 397 
Curschmann's spirals. 23, 64 
Cyanin blue stain, 285 
Cyanosis, effect of, on red 

count, 488 
Cyclic albuminuria, 228, 230 
Cylindrical epithelial cells in 
sputum, 27 
epithelium in stools, 398 
Cylindroids, 271 
Cylindruria, 275 
Cystic kidney, congenital, 

urine in, 319 
Cystin in urine, 260 

stones, 281 
Cystinuria, 260 
Cystitis, cultures in 294 
Cysts, echinococcus, in spu- 
tum, 26 
Cytodiagnosis of ascitic fluid, 
667 

of cerebrospinal fluid, 
665 

of pleural fluid, 667 

D 

Dahlia stain, 460 

Dare's alkalinometer, 544 

haemoglobinometer, 496 
Day and night urine, 92 
Deen's test, 364 
Deficit of HC1, 347 
saturation, 347 
Degeneration, amyloid, urine 
in, 316 

anaemic, of red corpuscles, 
479 

Degenerations of red cells, 
433- 434 



Delayed urea excretion, 330 
Desquamative nephritis, urine 
in, 311 

Desquamatory bronchial ca- 
tarrh, 67 
catarrhal pneumonia, 28 
Deutero-albumosuria, 237 
Diabetes insipidus, 204 
mellitus, 199 

blood in, 609 
Diabetic coma, 203 

leucocytes, in 529 
Diacetic acid, 195 
Diagnosis, functional renal, 
322 

surgical, value, 334 

Diamines in urine, 261 

Diarrhoea, 387 

anaemia due to, 556 
of children, blood in, 
608 

pancreatica 391 

Diastase in stools, 398 
in urine, 164 

Diazo-test, urine, 159 

Dicalcium phosphate sedi- 
ment, 252 

Differential counting, 508 

Differentiated inner body of 
erythrocytes, 476 

Diffuse nephritis, acute, urine 
in, 311 

Digestion, gastric, extent of, 
356 

products of, 357 
leucocytosis, 523 
starch, 357 
Digestive power of pancreatic 

juice, 385 
Dilated stomach, anaemia due 
to, 357 
contents of, 367 
Dilution test of urine, 331 
Dimethylamidoazobenzol, 344 
Dimethylamidobenzaldehyde 

test, 163 
Diphtheria, 83 
bacillus, 83 
blood in, 595 
Diplococcus lanceola'tus in 

sputum, 59 
Diploccccus pneumoniae, 59 
Dipylidium caninum, 418 
Diseases of kidneys, urine in, 
309 

Distoma haemotobium kid- 
ney, 419 
hepaticum, 416 
lanceolatum, 416 
Distribution of nitrogen in 

urine, 116 
Dittrich's plugs, 23 
Dried residue, determination 
of, 657 

Drigalski and Conradi's 

medium, 421 
Dropsical cells, 477 
Drugs, effect of, on red count, 

487 

Dry catarrh, 70 
Ducrey's bacillus, 302 
Duodenal ulcer, 375 
Dysentery, anaemia due to, 556 

stools in, 423 
Dyspepsia, anaemia due to, 
557 

nervous, 370 

E 

Easily split sulphates, 143, 

?47 

Echinococcus disease of kid- 
ney, 304, 321 
of lung, sputum in, 
26, 43 
Eclampsia, urine, 318 
Ectasis of stomach, 365 

hypertonic, 365 
Eel, vinegar, in urine, 306 



Effusion, pleural, leucocytes 
in 528 

Egg-yellow reaction, 163 
Egyptian haematuria, 305 
Ehrlich's classification of leu- 
cocytes, 505 
egg- yellow reaction, 163 
stains, 457 
Einhorn fermentation tubes, 
187 

Elastic tissue in sputum, 29, 

48 

pseudo-, in sputum, 
31 

Electrical conductivity, 329 
Emphysema, chronic bron- 
chitis of, 70 
Empyema, leucocytostis in, 
528 

perforating lung, 78 
Emulsions of leucocytes, 645 
Endocarditis, leucocytes in, 

_ S27 

Entamoeba coli, 404 

dysenteriae, 404 

histolytica , 404 
Enteritis membranacea, 394 
Enterogenous albumosuria, 
239 

Enteroliths in stools, 401 
Enthelmintha, 408 
Eosinophile granules, 502 

leucocytes, 506 
Eosinophilia, 534 

after tuberculin reaction, 
536 

bronchitis, 27 
due to parasites, 535 
in asthma, 535 
in diseases of bone mar- 
row, 534 
of genital organs, 536 
of haematopoietic organs, 
534 

of lymph glands, 535 

of spleen, 534 

of sympathetic nervous 
system, 537 

in malignant disease, 536 

in skin disease, 535 

medicinal, 536 

physiological, 534 

post-febrile, 536 
Eosinophilic bronchitis, 27 
Epicritical polyuria, 93 
Epiguanin, 122 
Episarken, 122 
Epistaxis, Gull's renal, 240 
Epithelial casts, 268 

cells in gastric contents, 
363 

in prostatic fluid, 307 
in sputum, 27 
in stools, 398 _ 
of urine sediments, 
265 

filtration, 332 
Erosions, hemorrhagic, of gas- 
tric mucosa, 375 
Erysipelas, leucocytes in, 

527 

Erythroblasts, 518, 519 

Erythrocystosis, 488 

Erythrodextrin, 189 

Esbach tubes, 215 

Essential albuminuria, 228 
renal haematuria, 240 

Ethereal sulphates, 138, 141 

Euglobulin, 219 

Eustrongylus gigas in kid- 
ney, 305 

Ewald-Boas test breakfast, 
34i . , 

Exercise, leucocytosis due to, 

53i 

Extent of gastric digestion, 
356 

Extraneous structures m spu- 
tum, 26 
Exudates, 666 



INDEX 



679 



F 

Faeces, 384 

False albuminuria, 224 
Famine fever, 643 
Fasciola hepatica, 416 
Fasting stomach, contents of, 
34i 

Fat in blood, 610 

in body fluids, 658 
in stools, estimation of, 
393, 

Fat-crystals of stools, 399 
Fate of nucleus of erythro- 
cytes, 515 
Fat-splitting ferment in gas- 
tric juice, 355 
Fatty acid crystals in spu- 
tum, 31, 33 
acids in stools, estimation 

of, 393 
casts, 269 
cells in sputum, 28 
concretions in urine, 282 
granules in leucocytes, 
504 

kidneys, urine of, 310 
stools, 390 
Febrile albuminuria, 233 
albumosuria, 239 
diseases, leucocytes in, 

^ , 52S - 

Fecal vomitus, 340 

Fehling's test, determination 

of sugar, 180 

Fermentation in gastric juice , 

361 

Ferment, fat-splitting, in gas- 
tric juice, 355 
of urine, acid, 107 
Ferments in stools, 398 

in urine, 164 
Ferrocyanide test, albumin- 
uria, 212 
Ferrometer, Jolles's, 499 
Fetid bronchitis, 71 
Fever, blood in, 558 
Fibres, muscle, in gastric 
juice, 362 
in stools, 397 
Fibrin casts in sputum, 24 
coagula in sputum, 24 
diagnosis, 467 
network in fresh blood , 
438 

structures in sputum, 24 
Fibrinogen, 218 

in body fluids, 657 
Fibrinoglobulin, 218 
Fibrinous bronchitis, 72 
Fibrinuria, 224 
Fibroid form of pulmonary 

tuberculosis, 46 
Filaria bancrofti, 641 

demarquai, 643 

diurnia, 642 

gigas, 643 

loa, 643 

megalhaesi, 643 

nocturna, 642 

ozzardi, 643 

perstans, 642 
Filariasis, 641 

Filtration, epithelial, kidney, 
332 

Fischer's < test meal, 342 
Fistula, jejunal, 386 
Fixation of complement, 651 
Fixing methods for smears, 
454 

Flagellata in cancer of stom- 
ach, 382 
in sputum, 43 
in stools, 404 
in urine, 304 
Flageilum stains, 285 
Fleischl haemoglobinometer, 
493 

Fluid, cerebrospinal, 661 
gastric, 338 



Fluid, pancreatic, 384 
prostatic, 306 
body, analysis of, 657 
Fluke, lung, 44 
Foetal blood, 521 
Folin's, acetone method, quan- 
titative determination, 
19S . 

ammonia method, 125 
standard diet, 385 
urea method, 116 
Follicular tonsillitis, blood in, 
526 

Foreign bodies in sputum, 26 
Form of stools, 387 
Fragments of cancer in gas- 
tric juice, 380 
of _ mucosa in gastric 

juice, 362 
of tissue in sputum, 22 

in sputum of abscess 

of lung, 77 
in sputum of gan- 
grene of lung, 77 
in stools, 402 
in urine, 278 
in vomitus, 341 
Free HC1, determination of, 
346 

Freezing point of urine, 323 
Frequency of defecation, 387 
Fresh blood, study of, 429 
Freund's method of determin- 
ing the acidity of urine, 
137 

Fuchsin, 285 
Fuchsinophilia, 478 
Fuchsinophilic cells, 513 
Functional albuminuria, 225 
renal diagnosis, 322 

surgical value of, 334 
Furbringer's hooks, 300 
Furfurol test, 118 

Q 

Gaffky's table, 53 
Gall sand, 400 

Gall-stone colic, blood in, 620 
Gall-stones, 399 

pseudo-, 400 
Gamete, 624 
Gametoschizont, 624 
Gangrene of lung, leucocytes 
in, 529 
sputum of, 75 
Gas bacillus, 289 
Gastric contents, 338 
acidity, 343 
abnormalities, 367 
bacteria in, 363 
blood in, 363 
blood-clots in, 381 

cancer ferments in , 
380 

crystals in, 362 
epithelial cells in, 363 
fragments of mucosa , 
362 

infusoria in, 362 
moulds, yeasts, sarci- 

nae in, 363 
mucus in, 372 
muscle fibres in, 362 
pus in, 362 
diagnosis without tube, 
352 

digestion, extent of, 356 
products of, 357 

juice, acidity of, 343 
ammonia in, 360 
bases of, 360 
fermentation of, 361 
ferments, 152 
physiology of, 350 

motility, 365 

mucosa, atrophy of, 373 

ulcer, 374 
Gastritis acida, 372 

acuta, 371 



Gastritis, chronica, 371 
phlegmonosa, 371 
purulentia, 371 
acute and chronic, anae- 
mia due to, 557 
Gastro-intestinal disorders, 

anaemia due to, 556 
Gastrosuccorrhcea, 368 
Gastroxynsis, 368 
Gelatine, 288 

General paresis, blood in, 608 

Genitalia, eosinophilia in dis- 
eases of, 536 

Genitalia, infection of, 297,302 

Gentian violet, 285 

Gerhardt's test, diacetic acid, 
1 97 

German measles, blood in, 
594 

Giant cells of bone marrow, 

520 

Giemsa s stain, 303 
Gigantocytes, 477 
Glanders of lung, 63 
Glassy casts, 270 
Globular richness, blood, 569 
Globulin in body fluids, 657 

serum, in urine, 218 
Glomerular insufficiency, 331 
Glucose, 166 
Glutoid capsules, 385 
Gluzinski's test, 382 
Glycerine agar, 288 
Glycogen in urine, 189 
Glycoproteids, 657 
Glycosuria, 166 
Glycuronic acid, 205 
Gonococcus, 298 
Gonorrhoeal cystitis, 295 
Gout, leucocytes in, 529 
Gouty albuminuria, 232 
Gowers's haemoglobinometer, 
494 

Gram's stain, 84 
Gram-negative organisms, 84 
Gram-positive organisms, 84 
Granular casts, 268 

cells in prostatic fluid, 
307 

masses of Schultze, 538 
Granules, acidophile, 502 

basophile, 504 

of Grawitz, 481 

eosinophile, 502 

fatty, 540 

Grawitz, 481 

haemokonien, 437 

in red cells in malaria, 481 

Mastzell, 502 

neutrophile, 504 

of red cells, 435, 480, 481 

oxyphilic, 502 

perinuclear, 504 

pigment, in sputum, 28 

sago, in sputum, 28 
Grawitz granules, 481 
Grawitz's unripe cell, 518 
Green sputum, 20, 57 

vomitus, 339 
Grinder's rot, sputum of, 21 
Grosse's method pepsin deter- 
mination, 3 55 
Growth, anaemia of, 606 
Gruber-Widal test, 470 
Guaiac test, 244 
Guanin, 123 

Gull's renal epistaxis, 240 
Gum, animal, in urine, 190 
Gunning's test, acetone, 192 
Gunzburg's reagent, 344 

H 

Haemamoeba leukaemia? 

magna, 588 
parva, 589 
malaria, 636 
virax, 624 
Haematochyluria, 642 
Haematocrit, 449 



680 



INDEX 



Hematogenous albuminuria, 

233 

albumosuria, 239 

jaundice, 152 
Haematoidin in sputum, 29, 34 

in urine sediment, 256 
Haematopoietic organs, 548 

eosinophilia in dis- 
eases of, 534 
Haematoporphyrin, 246 
Haematozoon falciparium, 629 
Hematuria, 240 

angioneurotic, 241 

Egyptian, 300 

essential, 240 

renal, 240 
Hemolytic system. 652 
Haemin test, blood in urine, 
244 

Haemoglobin, 490 

estimation of, 490 

in sputum, 20 

in urine sediment, 257 
Haemoglobinaemic degenera- 
tions, 43 4 
Hemoglobinometers, 490 
Hemoglobinuria, 241 

paroxysmal. 242 
Haemoglobinuric nephritis, 
312 

Hemokonien granules, 437 
Hemophilia, renal, 241 
Haemoptysical phthisis, 55 
Hemoptysis, 80 
parasitic, 44 
Hemosiderin crystals, 437 
Hammarsten's bile test, 158 
Hammerschlag's method of I 
determining pep- 
sin, 354 
of determining soe- 
cific gravity of 
blood, 461 
Hard chancre, organism of, 302 
Haser's coefficient. 97 
Hayem's fluid, 439 

hemocytometers, 448 
Hay's bile acid test, 159 
Healthy, albuminuria of ap- 
parently, 228 
Heart disease, blood in, 521 

effect of, on count of 
reds, 488 
Heat test, albumin, 209 

glucose, 177 
Heating smears, 454 
Hehner-Maly method, organic 

acids, 360 
Hehner's value, 303 
Heller's test, albumin, 210 

quantitative, 215 
blood, 243 
Hemorrhage, anemia due to, 
55 1 

in bronchiectasis. 74 

occult, in stools, 363 

pulmonary, in tubercu- 
losis, 55 
Hemorrhagic erosions of gas- 
tric mucosa, 375 

infarct of lung, 81 

nephritis, 240 

pneumonia, 57 

sputum, 19, 80 
Hepatogenous albumosuria, 

. 239 

jaundice, 151 
Hereditary albuminuria, 232 
Herzfehlerzellen, 29, 82 
Hetero-albumose, 256 
Hetero-albumosuria, 235 
Heterochylia, 368 
Heteroxanthin, 122 
Hippuric acid, 256 
test, 334 
His's capsule stain. 60 
Hodgkin's disease, 589 
Homogentisinic acid, 207 
Huhnerfeld's solution, 364 
Hunger diabetes, 166 I 



Huppert's bile test, 156 
Hyaline casts, 270 
Hydremia, 548 
Hyrdocele fluid, 674 
Hydrochinone, 10 1, 151 
Hydrochloric acid in gastric j 
juice, 344 
absolute amount, 349 | 
bound, 347 
deficit, 347 
quantitative deter- 
mination of, 346 
Hydrogen sulphide in urine, 
143 

Hydronephrosis, 321 
Hygrometry, 463 
Hymenolepis nana, 317 
Hyperaciditas hydrochlorica, 
367 

Hyperacidity. 367 
Hyperchlorhydria, 367 
Hyperkinesis, 368 
Hypermotility, 365 
Hypersecretion, 368 
Hypertonic ectasis, 365 
Hypocythemia, 548 
Hypoglycosuria, 334 
Hypoplastic anemia, 549 
Hypostatic albuminuria. 232 
Hypoxanthin, 123 

I 

Immature nucleated reds, 

512 ; 

Importance of casts, 274 
Inanition, anemia of, 555 
Index, color, 500 
volume, 501 
Indifferent Ivmphoid cells, : 
518 

Indigo calculi. 282 

carmine test. 337 

sediment, 257 
Indigo-blue in urine, 148 

-red in urine, 150 
Indoxyl sulphate in urine, 
146 

Indurative nephritis, urine 
in, 314 
pneumonia, sputum of, 61 
Infarction of kidney, urine 
in, 320 

Infectious disease, cause of 

anaemia, 557 
Infectious nephritis, urine in, 

293 

Inflammatory leucocytosis, j 
525 

Influenza, leucocytes in, 528 

sputum of, 61 
Infusoria in cancer of stom- 
ach, 382 
in intestine, 402 
in sputum, 43 
Inorganic acids in urine, 129 

bases in urine, 129 
Inoscopy. 669 
Inosite, 659 

in urine of diabetes insip- j 
idus, 205 
Insanity, blood in, 609 
Insipidus, diabetes, 204 
Insufficiency, glomerular and 
tubular, 331 
motor, of stomach, 365 
Intermediary bodies, 651 
Intermediate forms of nucle- 
ated reds. 513. 568 
Intermittent albuminuria, 1 

228, 232 
Interstitial gastritis, puru- 
lent, 371 
nephritis, urine in. 315 
pneumonia, sputum of, 61 
Intestinal cancer, blood in, 
615 

concretions, 401 
obstruction, leucocytes 
in, 527 



Intestinal parasites, 402 

cause of anemia, 559 
sand, 401 
worms, 408 
Intestine, contents of, 388 
motility of, 388 
tuberculosis of, blood in, 
,.599 

Intraligamentous ovarian 

cysts, fluid of, 674 
Iodide of potassium test, 334 
Iodine reaction in blood, 537 
Iodophilia, 537 
Iron in urine, 145 
Irritation forms of leucocytes. 

507 

Isomaltose, 190 
J 

Jaffe's test for creatinin. 127 
for indoxyl sulphate, 
148 

Jaundice, catarrhal, blood ir. , 
620 

hematogenous, 152 

hepatogenous, 151 

toxemic, 152 

toxic, blood in, 620 
Jejunal fistula, 386 
Jenner's stain, 460 
Joints, tuberculosis of, blood 

in - 599 
Jolles ferrometer, 499 

test, albuminuria. 213 
Juice, gastric, acidity of, 

343 

Justus's test, 617 

K 

Kahler's disease, 235 
Kaufmann's bacillus, 380 
Kidney, abscess of, blood in, 
529; urine in, 319 

acute nephritis, blood in, 

618; urine in, 311 
amyloid degeneration of. 

urine in, 316 
arteriosclerosis of, urine 

in, 3 IS 
atrophy of, urine in, 318 
cancer of, 319 
chronic passive conges- 
tion of, urine in, 310 
cloudy swelling of, urine 

in, 310 
congenital cystic, blood 

in, 620; urine in, 319 
diseases of, urine in, 309 
fatty, urine in, 310 
infarction of, 310 
large white, urine in. 

3i3 

nephritis, blood in, 618 

urine in, 311 
parasitic diseases cf. 321 
senile atrophy of, urine 

in, 318 
stone in, 321 
tuberculosis of. 319 
blood in. 599 
Klebs-Loffler bacillus, 83 
Kottidorfer's value, 393 
Kiilz and Vogel's test, pen- 
tose, 188 

L 

Labor, albuminuria of women 

in, 228 
Lacmoid, 544 
Lactic acid, 659 

in cancer of stomach. 
378 

in gastric juice. 357 
quantitative deter- 
mination of, 359 

Lactose, 185 

Laiose, 190 



INDKX 



681 



Lamblia intestinalis in stools, 
405 

Landois method of determin- 
ing blood alkalinity, 543 
Large lymphocytes, 518 
mononuclears, 505 
white kidney, urine in, 
3i3 

Latent constipation, 384 
Layer formation, sputum, 22 
Lead in urine, 146 

poison, cause of anaemia, 
560 

Lecithin, 568 

globules in prostatic 
fluid, 307 
Legal 's test, 191 
Leishman-Donovan bodies, 
640 

Leprosy, blood in, 621 
Leptodera intestinalis, 415 

stercoralis, 415 
Leptothrix innominata in spu- 
tum, 35 

maximus buccalis, 36 
Leucin, 658 

as sediment, 257, 259 

in sputum, 34 
Leucoblast, 519 
Leucocytes, 502, 505 

counting, 450 

emulsions of, 645 

fresh, 43 5 
Leucocytosis, abscesses, 529 

acute bronchitis, 528 

acute cerebrospinal men- 
ingitis, 526 

acute fibrinous pleurisy, 
S28 

acute follicular tonsilli- 
tis, 526 

acute ulcerative endo- 
carditis, 527 

bronchiestasis, 528 

cholera, 527 

chronic bronchitis, 528 

diabetic coma, 529 

empyema, 528 

endocarditis, 527 

erysipelas, 527 

exercise, 531 

fetid bronchitis, 528 

gangrene of lungs, 529 

gout, 529 

hydronephrosis, 529 

inflammations and feb- 
rile diseases,52S 

influenza, 528 

intestinal obstruction, 527 

malignant disease, 530 

meningitis, 526 

myxoedema, 527 

perirenal abscess, 529 

pleurisy with effusion, 528 

pyelitis, 529 

pyelonephrosis, 529 

pyogenic inflammations, 
S27, 528 

rabies, 527 

renal calculus, 529 

uraemia, 529 

whooping-cough, 526 

agonal, 531 

digestion, 523 

Mastzell, 532 

medicinal, 531 

mixed, 532 

of eosinophiles, 534 

of large mononuclears , 
53 2 

of new-born, 525 
post-hemorrhagic, 530 
post-operative, 536 
pregnancy, 534 

Leucopenia, 533 

Leucourobilin, 389 

Leukaemia, acute, 586 
lymphatic, 577, 583 
mixed, 577 

spleno-myelogenous, 577 



Leukaemia "parasite," 588 
Leukanaemia, 590 
Levulose, 184 
Levulosuria, 185 
Leyden (Charcot-) crystals in 
blood, 581 

in sputum, 34, 66 

in stools, 399 
Lieben's test, 192 
Lientery, 397 

Limit, assimilation for sugar, 
165 

Lipaemia, 609 

Lipase in urine, 164 

Lipuria, 264 

Litmus milk, 288 

Liver abscess, blood in, 620 
acute yellow atrophy, 

blood in, 622 
cirrhosis, blood in, 620 
diseases, blood in, 620 

Lobar pneumonia, blood in, 
601 

chlorides, in 130 
sputum of, 55 
Lobulated cells, 508 
Loffler's blood serum, 83 

methylene blue, 84, 284 
Lowits's organism, 588 
Lowy, alkalinity of blood, 544 
Lues, blood in, 615 

congenital, blood in, 607 
diagnosis of, 651 
organism of, 302 
Luetic nephritis, 235, 313 
Lung, abscess of, blood in , 
529; sputum of, 76 
actinomycosis of, sputum 
of, 42 

cancer of, sputum of, 82 
chronic passive conges- 
tion of, sputum of, 81 
echinococcus of, 43 
fluke, 44 

gangrene of, blood in, 
529; sputum of, 75 

glanders of, 63 

liver perforation through, 
77 

lues of, 83 
oedema, of 79 
stones, 24 

tuberculosis of, blood in, 
596; sputum in, 46 
Lymph glands, eosinophilia 

in diseases of, 535 
Lymphaemia, 583 
Lymphocytes, 505, 508, 518 
Lymphocytosis, 532 
Lymphoid cells of Wolff, 518 
Lymphomatosis, alymphae- 

mic, 534 

M 

MacNeal's stain, 304 
Macrocytes, 477 
Macrogamete, 624 
Macrophages, 438 
Macroscopic constituents spu- 
tum, 22 
Macroscopy of stools, 399 
Magnesium phosphate in 

urine, 144, 251 
Malaria, blood in, 590, 624 
granules in red cells, 480 
of children, 607 
Malarial parasites, aestivo- 
autumnal, 629, 636 
quartan, 627, 636 
tertian, 624, 634 
Malassey's haemocytometer, 
448 

Malignant diseases, hlood in, 
611 

eosinophilia in, 536 
gastric juice in, 351 
leucocytes in, 530 
of lung, sputum of, 82 
Maltose, 190 



Maly method (Hehner), 360 
Maragliano's endoglobular 

degeneration, 433 
Marrow, bone, 5 1 1 

cells of Troje, 5 1 8 
Masturbators, albuminuria of, 

229 

Mastzell granules, 502 
leucocytosis, 532 
Mastzellen, 506, 518 
Mature nucleated reds, 512 
Meals, test, 341 

Boas evening, 366 
Ewald-Boas, 341 
Fischer's 342 
lactic acid, free, 358 
Riegel's, 341 
Measles, blood in, 594 

German, blood in, 594 
Media for bacteria, 287 
Mediastinal growths, 82 
Medicinal eosinophilia, 536 

leucocytosis, 531 
Medicines, color of urine due 

to, 102 
Megaloblasts, 513 
Megalocytes, 477 
Megalogastria, 365 
Megalokaryocyte, 520 
Melanin, 100 

as urine sediment, 257 
Melanogen, 100 
Melituria, 190 
Mellitus, diabetes, 199 
Melting point of crystals, de- 
termination of, 174 
Membranous enteritis, 394 

ureteritis, 221 
Meningitis, leucocytes in, 526 
tuberculous, blood in. 
599 

Merozoite, 624 
Metalbumin, 670 
Methaemoglobin, 245 
Methylene-blue degeneration 
of Ehrlich, 480 
stains, 84, 425 
test in urine, 332 
urine, 102 
Methyl-violet test, 344 
Methylxanthin, 122 
Metrocytes, 517, 522 
Mett's method for pepsin de- 
termination, 354 
Microblasts, 515 
Micrococcus aureus, 291 

tetragenus in sputum, 36 
Microcytes, 477 
Microgamete, 624 
Microgametocyte, 624 
Microscopic constituents spu- 
tum, 26 
examination of gastric 
contents, 362 
Microscopy of stools, 398 
Miescher's haemoglobinome- 
ter, 491 

Miliary tuberculosis, sputum 
of, 46 

Milk curds in stools, 397 

litmus, 288 
Mineral acidity of urine, 107 
Minimal albuminuria, 222 
Mixed leucocytosis, 498 
Monocercomonas hominis, 375 
Monont, 590 

Mononuclears, eosinophile, 
473. 484 
large, 471 

increase of, 498 
neutrophile, 472, 483 
small, 471, 474, 484 
Moore's test, glucose, 169 
Moore and Wilson's method 

for alkalinity of blood, 546 
Morner's body, 219, 222 

method, urea, 114 
Morning sputum, 18 

star crystals in urine, 
249 



682 



INDEX 



Mosquito-cycle of malarial 

parasite, 631 
Motility of intestine, 384 
of stomach, 365 

determination of, 366 
ectasis, 365 
hypermotility, 365 
motor insufficiency, 
365 

salicylic-acid test, 

366 

Motor insufficiency, 365 
Moulds in gastric contents, 
363 

n sputum, 24 

in stools, 419 

in urine, 304 
Mouth flora, 88 
Mucin in body fluids, 219, 657 
Mucinuria, 221 

Mucoid in body fluids, 221, 
657 

sputum, 19 
Mucopurulent sputum, 19 
Mucor corymbifer, 37 

mucedo, 37 

pusillus, 38 

racemosus, 38 

ramosus, 38 

rhizopodiformis, 38 

septatus, 38 
Mucosa, atrophy of, 373 

fragments of, in gastric 
contents, 362 
Mucous colitis, 394 

threads in urine, 271 
Mucus in stomach, 342, 352 

in stools, 373 

in vomitus, 339 

sediment, 265 
Muller's blood dust, 437 
Murexid test, 120 
Muscle fibres in gastric con- 
tents, 362 
in stools, 397 
Myelaemia, 577 
Myelin in sputum, 28 
Myeloblast, 518 
Myelocytes, eosinophile, 507, 
518 

neutrophile, 506, 517 
Myelogenous leukaemia, 577 
Myelopathic albumosuria, 235 
Myxcedema, blood in, 622 

leucocytes in, 527 

N 

Naegeli's myeloblast, 518 
Nakayama's test for bile, 156 
Necrotic tissue fragments in 

sputum, 22 
Neinser's stain, 84 
Nematode worms in urine, 

305 

Nephritis, acute, 311 

diffuse, 311 

parenchymatous, 311 

albuminuria of, 234 

blood in, 618 

chronic diffuse, 313 
indurative, 314 
interstitial, 315 
parenchymatous, 313 

desquamative, 311 

haemoglobinurica, 312 

hemorrhagic, 240 

indurative, 314 

luetic, 313 

non-indurative, 313 

subacute, 313 

suppurative, 319 

unilateral, 318 

urine cultures. in, 293 
Nervous disease, blood in, 608 

dyspepsia, 370 

form of albuminuria, 234 

system, sympathetic, dis- 
eases of, eosinophilia 
in, 537 



Neusser's granules, 504 
Neutral sulphates, 142 
Neutrophile granules, 504 
Neutrophiles, small, 507 
New-born, albuminuria of, 
228 

leucocytes in, 525 
New growth in kidney, urine 
in, 319 
in mediastinum, spu- 
tum in, 82 
Night and day urine, 92 
Nitric acid in urine, 143 

test for albumin, 210 
for urea, 118 
Nitrogen of sputum, 19 
of urine, 109 

determination of, 1 1 1 
Nitrogenous balance, 109 

equilibrium, 109 
Nitrous acid, 144 
Non-indurative nephritis, 313 
Normal persons, sputum of, 
17 

Normoblasts, 512 

in pernicious anaemia, 565 
Nubecula, 103 
Nucleated reds, 512, 565 

Howell's mature and 
immature, 512 
Nuclei of reds, changes in, 

fate of, 515 
Nuclein bases, 122 
Nucleo-albumin, 219, 221 
Nucleohiston, 223 
Nucleoid, 476 
Number of red cells, 483 
Nummular sputum, 55 
Nutrition, effect of, on red 

count, 485 
Nycturia, 92 

Nylander's test, glucose, 171 

o 

Obermayer's test for indoxyl, 
148 

Occult hemorrhage in stools, 
363 

Ochronosis, 102 
Odor of sputum, 22 

of urine, 103 
(Edema, chloride retention in, 
131 

(Edema of lungs, sputum of, 
78 

(Esophagus, cancer of, blood 
in, 514 

Oidium albicans in sputum, 
42 

in stools, 419 
Oligaemia, 548 
Oligochromaemia, 500, 548 
Oligocythaemia, 483, 548 
Oligoplasmia, 548 
Oliguria, 93 

Oliver's haemocytometer, 448 
haemoglobinometer, 497 
Oocyst, 624 
Ookinet, 624 

Operation, leucocytosis after, 
529 

Oppler-Boas bacillus, 384 
Opsonic index, 644 
Opsonins, 643 
Orcin test, 188 

Organic acids in gastric con, 

tents, 360 
Organic acidity of urine, 108 
Organized sediments, 265 
Origin of casts, 273 

of red cells, 516 
Orthochromatic cells, 513 
Orthostatic albuminuria, 228, 

230 

Orthotic albuminuria, 228 

Osteoclasts, 520 

Ovarian cysts, fluid of, 671 



Oxalate, calcium, crystals in 
sputum, 34 
in urine, 254 
stones, 281 

Oxalic acid, 255 

Oxaluria, 253 

Oxybutyric acid, 198 

Oxyphilic granules, 502 

Oxyproteinic acid, 128 

Oxyuris vermicularis, 411 

P 

Page's method for finding 
bacilli in solid stools. 421 

Palpation, albuminuria due 
to, 233 

Pancreatic disease, stools in, 
424 
fluid, 384 

digestive power of, 
385 

secretion in vomitus, 339 

stones, 401 
Pancreon test, 424 
Paper, Congo red, 344 
Paraceilaire albuminuric 232 
Paracresol, 151 
Paragonimus westermanii, 44 
Paramaecium coli, 407 
Paramucin, 671 
Parasites, anaemia due to, 
559 

animal, in lung, 43 

in urine, 304 
eosinophilia in, 535 
in vomitus, 341 
intestinal, 402 
plant, in sputum, 35 
in stools, 419 
Parasitic haemoptysis, 44 
Paratyphoid bacillus, 289 
Paraxanthin, 122 
Parenchymatous nephritis, 
acute, urine in, 311 
chronic, urine in, 313 
Paresis, blood in, 608 
Parovarian cyst fluid, 673 
Paroxysmal haemoglobinuria, 
242 
polyuria, 94 
Pathological amounts of 
urine, 93 
variations in red count, 
487 

Pavement-epithelial cells in 

sputum, 27 
Pavy's disease, 228 
Penicillium glaucum, 41 

nummula, 42 
Pentoses, 186 
Pentosuria, 186 
Penzoldt's test, 364 
Pepsin, 352 

quantitative method, 
Volhardt's method, 354 

in urine, 164 
Peptonuria, 237 
Perforating empyema, lung, 
78 

pleurisy, serous, 78 
Pericardial fluid, 670 
Perinuclear granules of Neus- 

ser, 513 
Periodic polyuria, 94 
Perirenal abscess, leucocytes 

in, 529 

Peritoneal fluid, analysis of, 
667 

Peritonitis, tuberculous, blood 

in, 599 
Permeability, renal, 332 
Pernicious anaemia, 561 

gastric juice jn, 351 
Pertussis, leucocytes in, 526 
Pettinkofer's reaction, 158 
Phagocytic cells in leukaemia, 

581 

Phagocyosis, 643 
Pharyngomycosis, 36 



INDEX 



683 



Phenol in urine, 147 
Phenolsulphuric acid, 151 
Phenylhydrazin test for glu- 
cose, 173 
Phlegmonous gastritis, 371 
Phlorizin test, 334 
Phosphate concretions, 281 

crystals in sputum, 34 
Phosphates, calcium, 252 

in urine, 133 

magnesium, 252 

triple, 251 
Phosphaturia, 105 
Phosphaturique albuminurie, 
_ 232 

Phosphorus-containing pro- 

teids. 657 
Phosphorus poisoning, red 

count, 487 
Phthisis, blood in. 596 
haemoptysical, 55 
melanotica, 28 
stone-cutters, 21 
Physiological albuminuria. 228 
eosinophilia, 534 
variation in red count, 
484 

Physiology of gastric secre- 
tion, 350 
Piffaud's method for staining 

bacteria, 285 
Pigment, bile, in sputum, 20 
in urine, 151 
blood, in sputum, 20 
coal, in sputum, 21, 28 
of urine, 146 
Pigmented cells in blood, 520 

in sputum, 28 
Piroplasmosis, 630 
Pittsfield's method, 286 
Placental cells, 438 
Plant parasites in sputum, 
35 

in stools, 419 
in urine. 306 
Plasmodium prsecox, 629 

vivax, 624 
Plastic bronchitis, sputum of, 
72 

Platelets of blood, 538 
Plaut's angina, 88 
Plehn's granules. 480 
Plethora vera, 548 
Pleural fluid, analysis of, 
667 

cytodiagnosis of, 667 
Pleurisy, acute fibrinous, leu- 
cocytes in, 528 
serous, perforating, spu- 
tum, in 78 
with effusion, leucocytes 
in, 528 
Plugs, Dittrich's, 23 

prostatic, 318 
Pneumaturia, 304 
Pneumoconiosis, 21, 83 
Pneumoliths, 25 
Pneumonia, abscess of lung, 
78 

blood in, 601 
broncho-, blood in, 604 

sputum of, 61 
chlorides in, 130 
chronic, sputum in, 61 
croupous, sputum in, 55 
desquamatorv catarrhal, 
28 

hemorrhage, sputvfm in, 
57 

interstitial. 61 

sputum of, 55 

subacute, sputum in, 62 
Pneumonomycosis aspergil- 

lina, 39 
Poikilocytes, 476, 565 
Poisons, anaemia due to, 560 
Polar granules, 84 
Polariscope, 180 
Polychromatophilia. 479- 565 

partial, 480 



Polychrome methylene-blue 

stains, 459 
Polycyclic elimination, 332 
Polycythemia, 483 
Polymorphonuclear leuco- 
cytes, 506 
Polyplasmia, 548 
Polyuria, epicritical, 93 
paroxysmal, 94 
periodic, 94 
Poor, anaemia of the, 555 

food, anasmia clue to, 
555 

Post-febrile eosinophilia, 536 
Post-hemorrhagic anaemia, 
55i 

Post-infectious albuminuria, 
232 

Postural albuminuria, 228, 
_ 230 

Potassium ferrocyanide test 
for albumin, 212 
in urine, 145 
iodide test, 334 
Precipitins, 651 
Pregnancy, ammonia in, 123 
leucocytosis of, 524 
red cells in, 485 
Pregnant women, albumi- 
nuria of, 228 
Pregoutteuse albuminurie, 
232 

Preservation of sediments, 
246 

of urine, 90 
Primary anaemia, 549, 561 

pernicious anaemia, 561 
Productiva, pyelitis, 221 
Products of gastric digestion, 
_ 357 

Progressive pernicious an- 
aemia, 549, 561 
Proliferating cysts, Pfltiger's 

tubules, 672 
Prostatic casts, 308 

fluid, 306 

plugs, 300 
Prostatitis, 301 
Prostatorrhcea, 301 
Proteids in body fluids, 657 

of urine, 217 
Proteus bacillus, 290 

cystitis, 295 
Protoleucocytes, 518 
Protoryxomyces coprinarius, 
405 

Prune-juice sputum, 57 
Pseudo-casts, 272 
Pseudodiphtheria bacilli, 84 
Pseudo-elastic tissue, 31 
Pseudo-gall-stones, 400 
Pseudoglobulin, 218 
Pseudoleucocytosis, 530 
Pseudoleukemia, 589 

of children, 607 
Pseudolymphocytes, 507 
Pseudomucin, 671 
Pseudothisis calculosa, 25 
Puberty, albuminuria, of 228 
Pulmonary actinomycosis, 42 

cancer, 82 

echinococcus disease, 43 
gangrene, 75 
infraction, 81 
lues, 83 

tuberculosis, blood in, 596 
sputum in, 46 
Purdy's fluid, 178 
Purin bases, 122 
Purulent gastritis, 371 
Pus casts, 270 

cells in prostatic fluid, 
307 

formation, anaemia due 

to. 558 . 
in gastric juice, 362 
in sputum, 27 
in stools, 396 
in urine, 278 
masses in sputum, 22 



Putrid bronchitis, sputum of, 
„ 7i 

Pycnometer, 460 
Pyelitis, leucocytes in, 529 
Pyelitis, cultures in, 294 

cultures in, 294 

urine in, 310 
Pyelitis productiva, 221 
Pyelonephritis, 310 
Pyelonephrosis, leucocytes in, 
529 

Pyloric stenosis, 366 

Pyocyanin, 290 

Pyogenic albumosuria, 239 

inflammations, leucocytes 
in, 527, 528 
.Pyonephrosis, urine in, 311 
Pyrocatechin, 10 1, 151, 



Quadriurates, 120, 248 
Quartan malaria, parasite of, 

627, 636 
Quotient, albumin, 217 



Rabies, blood in, 527 
of sputum. 19 
of stools, 387 
of urine, 103 
Rectum, cancer of, blood in, 
615 . 
stools in, 424 
Red cells, 429, 475 

color of, 432 
counting methods, 
438 

crenated, 430 
deformed, 430, 476 
degenerations of, 433, 

479 . 
granules m, 435, 481 
in sputum, 29 
in urine, 240, 279 
nucleated, 512 
number of, 483 
resistance of, 489 
shape of, 430, 476 
size of, 431. 477 
structure of, 476 
indigo, in urine, 150 
pepper granules, 248 
Reducible body of Stokvis, 
i54 

Reichert-Meissl value, 393 
Reichmann's disease, 368 
Relapsing fever, 643 
Renal abscess, urine in, 
319 

atrophy, 318 

urine in, 318 
calculus, 280, 321 

leucocytes in, 529 
concretions, 280 
diagnosis, 322 
disease, albuminuria, 234 
blood in, 618 
urine in, 309 
epistaxis, 240 
epithelial cells in urine, 
265 

haematuria, 240 
haemophilia, 241 
Rennet, 356 

Residuale albuminurie, 322 
Residue of dried blood, 463 
Resistance of red blood, 
489 

Retention of chlorides. 131 
Rhabditis stercoralis, 315 

strongyloides, 315 
Rheumatism, acute articular, 

blood in, 605 
Rice-water vomitus, 340 
Rickets, blood in, 608 
Riegel's meal, 341 
Rigler's method, alkalinity of 

blood, 545 



684 



INDEX 



Ring body of Cabot, 480 
Roberts method, quantity of 

albumin, 216 
quantity of glucose, 

183 

Rosenau's blood agar, 288 
Rosenbach's reaction, 158 

test, bile, 155 
Rot, grinder's, sputum of, 
2 1 

Rubner's test, glucose, 176 

lactose, 186 
Rusty sputum, 20 

s 

Saccharomyces busse, 36 
Saccharomycosis, 36 
Sago granules in sputum, 28 
Sahli's haemometer, 496 
Salicylic acid test for gastric 
motility, 366 
of renal suffi- 
ciency, 333 
Salkowski's method of deter- 
mining the alkalinity 
of blood, 545 
test for pentose, 187 
Sand, gall, 400 

intestinal, 401 
Saprophytes in urine, 306 
Sarcinae in gastric contents, 
363, 380 
in stools, 419 
in urine. 304 
Sarcoma, blood in, 615 
Saturation deficit, 347 
Scarlet fever, blood in, 595 
Scheme for sediments, 261 
Schistosoma haematobium in 
stools, 419 
in urine, 305 
Schizogone, 624 
Schizont. 624 
Schlesinger's test, 390 
Schlosing method for ammo- 
nia determination, 124 
Schmalz tubes, 460 
Schmidt's method bilirubin 

in stools, 389 
Schonbein's test for blood, 244 
Schondorff method, urea de- 
termination, 115 
Schottilius enriching method, 
423 

Schultze's granular masses, 
538 

Sclerosis (arterio-) of kidney, 
urine in. 315 

Scurvv. blood in, 622 

Scybala. 387 

Secondary anaemia, 549 

Secretion, continuous, of gas- 
tric juice, 368 
gastric, physiology of. 350 
of water by stomach, 365 

Sedimentation of red blood- 
corpuscles, 463 

Sediments, urine. 246 
bilirubin, 256 
carbonates, 251 
cholesterin, 257 
cystin, 260 
haematoidin, 256 
haemoglobin, 257 
heteroalbumose. 256 
hippuric acid, 256 
indigo, 257 
leucin, 257. 259 
melanin, 257 
mucous. 265 
organized. 265 
oxalates. 253 
phosphates, 251 
preservation, 246 
scheme, 261 
tyrosin, 257. 259 
unorganized. 248 
urates. 248 
xanthin. 256 



Senile atrophy of kidney, 

urine in, 318 
Septicaemia, blood in, 593 
Septicaemia, urine in, 293 
" Seromucus sputum," 67 
Serous cysts, ovarian, 671 

pleurisy perforating 

through lung, 78 
sputum, 19 

of iiedema of lung, 
78 

Serum albumin in urine, 217 
diagnosis, value of, 475 
globulin in urine, 218 

Seven-glass test, 301 

Sex, effect on count of red 
cells, 484 

Shape of red cells, 476 

Showers of casts, 275 

Siderosis, 2 1 . 83 

Silicic acid in urine, 143 

Size of casts, 272 

of red cells, 477 

Sjoqvist's method of urea de- 
termination, 114 

Skatoxyl, 149 

Sirin, eosinophilia in diseases 
of, S3 5 

Small mononuclears, 505, 508, 
5i8 

neutrophils, 507 
Smallpox, blood in, 595 
Smears, blood. 452 
Smegma bacillus, 286 

bacilli in urine, 286 
Soaps in stools, 393 

determination, 393 
Sodium in urine, 145 
Soft chancre, organism of, 302 
Specific gravity of blood, 460 
of body fluids, 657 
of urine, 95 
method of determining 
glucose, 183 
Spectroscope, 245 
Spermatocele, 674 
Spermatorrhoea, 301 
Spermatozoa, 307, 308 
Spermin crvstals in prostatic 

fluid, 308 
Spiegler's albumin reagent, 
213 

Spirals, Curschmann's, 23, 64 

Spirillum cholerae asiaticae, 422 
of Deneke, 423 
of Massea, 423 
of Metchnikoff, 423 
schuylkiliensis. 423 

Spirochaete of mouth, 88 
of Obermeier, 643 

Spirochaete pallidum, 302 
refringens, 304 

Spleen, eosinophilia in dis- 
eases of, 534 

Splenic anaemia, 561 

Splenomegalv, red cells in, 
488 

Spore stains. 285 
Sporoblast, 624 
Sporogone, 624 
Sporozoit, 624 
Sputum, 17 

air in, 22 

amount, 18 

animal parasites of, 43 

bacteria in, 59 

bile-stained, 20 

blood in,- 29 

bloody, 20 

character of, 19 

chemical analysis of, 45 

children's, 18 

color of, 19 

consistency of, 19 

crystals, 33 

foreign bodies in, 26 

green, 20, 57 

haemoglobin stained, 20 

macroscopic, 22 

microscopic, 26 



Sputum, morning, 18 

mucoid, 19 

mucopurulent, 19 

nitrogen of, 19 

normal persons, 17 

odor of, 22 

plant parasites, 35 

prune-juice, 57 

purulent, 19 

reaction of, 19 

rusty, 20 

sarcinae, in 36 

serous, 19 

yeasts in, 36 
Sputum coctum, 66 

crudum, 65 

globosum, 55 
Staining casts, 276 

properties of cells, 479 

vital, 480 
Stains for bacteria, 284 

for blood, 466 
Staphylococcus epidermidis 
albus, 292 

pyogenes albus, 291 

pyogenes aureus, 291 
Starch, digestion of, 357 
Stippled cells. 481 
Stokvis reducible body, 154 

test, bile, 156 
Stolinkow's method of quan- 
titative albumin, 216 
Stomach, absorption power of, 
364 

aseptic condition of, 340 

bacteria in. 363 

cancer of, blood in, 613 

contents, 338 

dilated, 366 

fasting, 341 

motility of, 365 

sarcinae in, 363 

ulcer of, 374 
Stomatomycosis, 36 
Stone in bladder, 280 

in kidney, 280, 321 

in lung, 24 

in ureter. 321 
Stone-cutters' phthisis, 21 
Stones, gall, 399 

intestinal, 401 

pancreatic, 401 

pseudo-gall, 400 
Stools, acoholic, 388, 390 

albumin in, 397 

bacteria in, 396 

bile pigments in, 389 

blood in, 394 

carbohydrates in, 397 

clay-colored, 388 

color of, 388 

concretions in, 400 

consistency of, 386 

constituents of. 386 

crystals in, 398 

epithelium cells in. 398 

examination of. 386 

fatty, 390 

ferments in, 398 

forms of, 387 

frequency of, 387 

in disease, 421 

in pancreatic disease, 424 

macroscopy, 399 

microscopy, 398 

mucus in, 393 

muscle-fibres in, 337 

parasites in, 402 

method of preserving, 425 

reaction of, 387 

starch in, 397 
Strassburger's bile-acid test, 
159 

Strauss' test, lactic acid, 358 
Streptococcus cystitis, 295 

pyogenes, 292 
Streptothrix pseudotubercu- 
losa, 35 

Strongyloides intestmahs. 415 
anaemia due to, 559 



INDEX 



085 



Structural albuminuria, 225 
Structure of red cells, 476 
Subacidity in cancer of stom- 
ach, 377 
Subacute indurative pneu- 
monia, sputum in, 62 
nephritis, urine in, 313 
Succinic acid, 658 
Sulphates of urine, 138 
easily split, 143 
ethereal, 138, 141 
neutral, 142 
total, 138 
unoxidized, 139 
Sulphide of hydrogen in 

urine, 143 
Sulphocyanic acid, 143 
Sulphur, bile-acid test of 

Hay, 159 
Superacidity, 367 
Supersecretion, 368 
Suppurative nephritis, urine 
in, 319 

Surgical values of tests (renal 

functional), 334 
Sympathetic nervous system, 

eosinophilia in diseases of, 

537 . 

Synovial fluid, 670 
Syphilis, albuminuria of, 313 
lung. 83 

nephritis, in 313 
organism of, 302 



Table for detection of calculi, 
282 

Taenia cricumerina, 418 
nana, 417 
saginata, 416 
solium, 416 
Tallqvist scale, 498 
Tanret's solution, 213 
Teichmann's test, 244 
Temperature, effect of, on 

count of reds, 485 
Tertian malaria, 624, 634 
Test meal, Boas evening, 366 
breakfast, 341 

lactic acid free, 
358 

Ewald-Boas, 341 
Fischer, 342 
Riegel, 341 
Testicle, cancer of, blood in, 

615 

Testicular casts in urine, 277 
Tetanus, bacillus of, 291 
Tetragenus, micrococcus, in 

sputum, 36 
Therapeutic measures, effect 

of, on count of reds, 487 
Thionin stain, 460 
Thiosulphuric acid, 143 
Thoma-Zeiss blood counter, 

438 

Thoracentesis, cause of albu- 
minous expectoration, 79 
Thornapple crystals, 249 
Threads, mucus, in urine, 
271 

Throat cultures, 83 
Tide, alkaline, 105 
Tissue, elastic, in sputum, 29, 
48 

Tissue fragments in sputum, 

22 

in urine, 278 
lung, in gangrene, 76 
pseudo-elastic, in sputum, 
31 

Toisson's fluid, 439 
Tonsillitis, leucocytes in, 526 
Topfer's method. 348 
Tophus, 674 

Total acidity, gastric, 348 
of urine, 107 
organic acids in gastric 
juice. 360 



233 
para- 



414 



Toxaemic jaundice, 152 
Transitional leucocytes, 505 
Transparent cells, 508 
Transudates, 666 
Traumatic albuminuria 
Trematode worms as 

sites, 416 
Trepanoma pallida, 302 
Trichina spiralis, 408 
Trichiuris trichiura, 414 
Trichocephalus dispar, 
Trichomonas hominis, 405 

intestinalis, 375 

pulmonalis, 43 

vaginalis, 405 

in urine, 304 
Triple phosphate, 251 

concretions, 301 
Tripperfaden in urine, 300 
Troje's marrow cell, 518 
Trommer's test, glucose, 168 
Tropaeolin 00, 344 
Tropics, anaemia of, 557 
Trousseau's test, bile, 156 
True albuminuria, 224 
Trypanosomiasis, 638 
Trypsin, 384 

in stools, 398 

in urine, 164 
Tyrptophan test, 381 
Tubercle bacilli in sputum, 

. 49 " 

m stools, 420 

in urine, 286 
Tubercle bacillus, 49 

isolation, 49 

prognostic value, 53 

staining, 50 
Tuberculosis, blood in. 596 

acute miliary, blood in 
598 

adrenals, blood in, 599 

of bladder 294 

bones and joints, blood in, 

599 

chronic, of lungs, blood 

in. 597 
intestine, 599 
kidneys, blood in, 599 

urine in, 319 
lymph glands, blood in, 

590 , , . • 

meningitis, blood m, 599 
peritonitis, blood in, 599 
pulmonary, acute miliary, 

46 

bronchopneumonia, 
47 

chronic ulcerative, 
47 

fibroid form, 46 

haemophysical, 55 

sputum, of 46 
Tubo-ovarian cysts, 673 
Tubular insufficiency, 331 
Tumor fragments in gastric 
juice, 380 

in stools, 402 

in urine, 278 
Typhoid bacillus, 289 

in stools, 421 
Typhoid fever, blood in, 599 

stools in, 421 
Typhus fever, blood in, 594 
Tyrosin, 658 

in sputum, 34 
in urine, 257, 259 

u 

Udransky's test, bile acid, 159 
Uffelmann's test, lactic acid. 
358 

Ulcer of duodenum, 375 

of stomach, 374 
Ulceration, chronic tubercu- 
lous, sputum in, 47 
Ulcinaria americana. 411 

duodenalis, 411 
Uncinariasis, anaemia in, 559 



Unilateral nephritis, 318 
Unorganized sediment, 248 
Unoxidized sulphur in urine, 
139 

Unripe cell of Grawitz, 518 
Uraemia, leucocytes in, 529 

urine in, 317 
Urate, calcium, 250 

casts, 272 

concretions, 280 

sediment, 248 
Urea, 113 

crystals, 674 

delayed excretion of, 330 

estimation, 113 

in blood, 547 

isolation, 117 

properties, 117 

tests, 117 
Urethra, infection of, 297 
Urethritis, 297, 299 
Ureteral calculus, 311 
Ureteritis, membranous, 221 
Uric acid, 117 

concretions, 280 
crystals, 249 

Urine, 90 

mineral acidity, 107 
organic acidity, 108 
total acidity, 107 
amount of, 91 
animal parasites in, 304 
bacteria, 283, 292 
bile in, 151 
bile acids in, 158 
blood in, 260 
bile acids in, 158 
blood in, 260 
carbohydrates in, 165 
centrifugalization of, 284 
collection of, 90 
color of, 97 
concretions in, 280 
cryoscopy, 323 
cultures of, 283 
day and night, 92 
ferments of, 164 
freezing point of, 323 
general appearance of, 90 
character of, 90, 103 
glucose in, 168 
inorganic acids and bases, 
129 

moulds in, 304 

nitrogenous bodies in, 107 

odor of, 83 

pigments in, 146 

plant saprophytes in, 304 

preservation of. 90 

proteids of, 217 

reaction of, 103 

sarcinae in, 304 

sediments, 246 

specific gravity of, 95 

yeasts in, 304 
Urines, black, 102 
UroDilin, 98 
Urochrome, 98 
Uroerythrin, 98 
Uroleucinic, acid, 207 
Uronephrosis, 321 
Urorhodin, 150 
Urorosein, 151 
Urorubin, 150 



Value, acid, 393 
Hehner's. 393 
Knttsdorfer's, 393 
Reichert-Meissl, 393 
surgical, of functional 
diagnosis, 334 

Variations in red count, path- 
ological, 484 

Vegetable parasites in urine- 
304 

Vermiculus. 624 
Vesical calculi, 280 
Vincent's angina, 88 



686 



INDEX 



Vinegar eel in urine, 306 

Vital staining, 480 

Volhardt's method, quantita- 
tive pepsin determination, 
354 

Volume index, 501 
Vomitus. bile in, 339 

blood in, 339 

fecal, 340 

green, 339 

mucus in, 339 

pancreatic fluid in, 339 

parasites in. 341 

rice-water, 340 



w 

Water secretion in stomach, 
Vv axy casts, 269 



Weidel's test, purin bases, 123 
Weich's capsule stains, 59 
Weyl's test, creation, 127 
Whetstone crystals of uric 

acid, 249 
of xanthin, 256 
White cells, 505 

kidney, large, urine in. 3 16 
Whooping-cough, leucocytes 

in, 526 

sputum of, 63 

Widal test, 470 

Williamson's blood test, 610 

Worms, mounting, 425 

nematode, of urine. 305 
round, in stools, 408 
staining methods, 425 

Wright's method, opsonic in- 
dex, 645 
tubes for coagulation, 465 



Xanthin bases in urine, 122 

crystals, 256 

stones, 281 
Xerosisbacilli, 88 
Xvlose, 187 



Yeasts in gastric contents, 363 

in sputum, 36 

in stools, 419 

in urine, 304 
Yellow fever, anaemia in, 264 



Zygote, 624 



mi 



